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Nicole Marie

Prices are CAD$
All prices include applicable taxes.
Prices in USD are estimated.

Intake Form

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

If you have already filled out a form for an individual session, 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

Do you have any medical conditions I should be aware of before your session?*

Are you taking any medications that may impair alertness or awareness?*

Are you currently under the care of a healthcare professional for a condition that would be relevant to this session?*

Yes

No

Check ALL 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

History of Seizures

Severe Panic Disorder

Severe Mental Health Conditions

None of the above apply

Consent*

I consent to receive Hypnosis from Nicole Marie

I voluntarily agree to participate in these services

I confirm that I have disclosed any relevant medical conditions to the best of my knowledge

I understand that results may vary and that I am responsible for my own well-being during and after sessions

I have read and agreed to ALL CONSENT TERMS

LIABILITY

I agree to release Nicole Marie from liability for outcomes arising from participation in these services

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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