Intake Form

ALL INFORMATION IS STRICTLY CONFIDENTIAL.

First Name

Address

State

Last Name

City

Zip Code

Phone Number (Home)

Occupation

Phone Number (Work)

Employer

Email Address

Single Or Married?

Single Married Divorced/Separated

Mother's Name

Mother's Age

Mother Alive?

Alive Deceased

Father's Name

Father's Age

Father Alive?

Alive Deceased

Do you wear contacts

Yes No

Do you wear false teeth?

Yes No

Have you used recreational drugs?

Yes No

Is there any reason, either physical or mental, why you cannot undergo hypnotherapy?

Yes No

Religious affiliation

Release

I release MASTERYWORKS INC. and all its employees and agents, from any and all claims that may result from this procedure. I hereby agree to, and voluntarily consent to, undergo hypnosis. I do declare that I have read this release and consent that I understands its terms.

Consent

I, the undersigned, understand that hypnotherapy and EFT is a conditioning process whereby an individual is taught to use his or her own abilities for his/her own benefit, also that it can sometimes take several sessions for good, long lasting results.

Signed

Type your name as signature

EFT Disclaimer

EFT DISCLAIMER

Masteryworks Inc. makes no claims, implied or otherwise, regarding the success and/or results from the application of EFT and/or personal coaching/counseling (hereinafter referred to as "services") provided by Masteryworks Inc. These services are considered experimental, and although success rates are in the 80% - 90% range, they are as yet undocumented therapies. Ellie McFalls is NOT a licensed physician, therapist, or psychologist. Ellie McFalls holds a certificate as EFT Level 2 Practitioner. The emotional or physical frailty of some people is such that they should not attempt ANY healing procedure without the presence of a LICENSED THERAPIST. This may be 2% - 3% of the population. If you are in this category, YOU MUST BE ACCOMPANIED BY YOUR MENTAL HEALTH CARE PROVIDER. You take full responsibility for your personal health and safety. Your compliance with all of your current medical treatments, therapies, and prescriptions is expected. Masteryworks Inc. shall not be liable for any damages or injury arising out of your access to, or inability to access, the services provided. Masteryworks Inc., disclaims any and all liability for direct, indirect, incidental, consequential, punitive, special or other damages, lost opportunities, lost profit, or any other loss or damages of any kind.

RELEASE

By my signature below, I affirm that the information I have provided above is accurate and true, and that I freely enter into this legally binding agreement and acknowledge that I understand and agree with the disclaimer presented above. Also, by my signature, I, and my heirs, in consideration of my participation in the services provided by Ellie McFalls and/or Masteryworks Inc., hereby release Ellie McFalls, her family, and the officers, employees, and agents of Masteryworks Inc. from any and all liability for any loss or damage caused, or alleged to have been caused, directly or indirectly, by the services provided and/or the information or ideas contained, suggested or referenced during the course of the services provided. I understand that my participation in the services provided is strictly voluntary, at my on risk, and I freely choose to participate. I understand that Ellie McFalls and Masteryworks Inc. do not provide medical treatments and/or coverage and I verify that I will be responsible for any and all medical costs I incur, directly or indirectly, as a result of my participation.