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Nicole Marie

Prices are CAD$
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Prices in USD are estimated.

Group Intake Form

Your information will be kept confidential and used only for the purpose of providing hypnosis.

If you have already filled out a GROUP FORM, this is not required.

First name*

Last name*

Email*

I understand this form is CONSENT and I need to fill out a BOOKING FORM to book a session*

Already submitted

Will do after this form

Check any that apply to you:*

Schizophrenia

Bipolar Disorder

Active Psychosis

Severe Disassociation

Active Suicidal Ideation

Taking Heavy Sedatives

Severe/Complex PTSD or Trauma

Borderline Personality Disorder

Severe Panic Disorder

History of Seizures

Severe Mental Health Conditions

None of these apply to me

NATURE OF THIS SESSION TERMS; I UNDERSTAND THAT:*

This session is a group session delivered via Zoom

This is NOT individualized or medical treatment

The facilitator CANNOT provide personal care or crisis intervention during the session

I acknowledge and understand ALL NATURE OF THE SESSION TERMS

SAFETY TERMS; I CONFIRM THAT:*

I will NOT participate under the influence of alcohol, recreational drugs, any non-prescribed substances that may impair awareness or judgement

I am responsible for ensuring a SAFE environment

I will NOT be driving or operating machinery during the session

I will end participation if I feel uncomfortable or unsafe

I am responsible for managing my own well-being during and after the session

I acknowledge and agree to ALL SAFETY TERMS

MEDICAL TERMS; I CONFIRM THAT:*

I understand that participation in hypnosis may involve: emotional responses, deep relaxation, personal insights or other internal experiences

I am responsible for ensuring I am fit to participate and will consult a medical professional if I am unsure.

I understand that certain medications or health conditions may affect my experience and will consult a medical professional if I am unsure

I acknowledge and understand ALL MEDICAL TERMS

CONSENT TERMS; I CONFIRM:*

I voluntarily agree to participate in this group hypnosis and give informed consent

I understand that I am participating at my own risk

I confirm I have read this form and understand this form

I acknowledge and agree to ALL CONSENT TERMS

I have read and agree to ALL TERMS in this form and release Nicole Marie from any responsibility for outcomes related to my participation

Today's Date*

Signature*

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DISCLAIMER: I, Nicole Marie, am not a medical doctor, psychiatrist, or psychologist, nor do I carry any sort of license to practice medicine. I do not diagnose, prescribe, or provide medical treatment. All healing is self healing and voluntary. I recommend that clients continue to see their regular medical doctors and follow their advice. The work that I do does not take the place of conventional medicine or treatment for any medical or psychological condition. If you are in need of medical treatment, diagnosis, or psychological care, you should seek the proper licensed physician or healthcare professional. My spiritual work is not for everyone, nor does it have the same results or outcome for everyone. I do not make any guarantees, warranties, or promises in regards to the results or outcome of my spiritual work.

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