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Hypnosis Appointment Forms

Please complete ALL 3 FORMS at least 1 hour prior to your appointment.

Remember to click SUBMIT at the bottom of each form.

FORM # 1

Confidential Client Record for Hypnosis

This form must be completed before your appointment begins.

Type of Hypnosis Appointment*
I have read this Statement of Release. I understand and agree to all of the above. My typed name below represents my signature:
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Thank you for submitting FORM # 1. Please complete FORM # 2 below.

FORM # 2

Hypnosis Responsiveness Questionnaire

This form must be completed before your appointment begins.

1. Have you ever been hypnotized?*
2. Have you ever seen someone hypnotized?*
3. Do you believe hypnosis can help you with your problems?*
4. Have you ever walked or talked in your sleep?*
5. Are you basically a trusting person?*
6. Do you have a good imagination?*
7. Do you daydream?*
8. Are you able to concentrate on an idea or thought?*
9. Have you or do you listen to Guided Meditations?*
10. Are you open to new ideas?*
11. Are you able to follow directions?*
12. Are you able to get in touch with your emotions easily?*
13. Do you believe that it's possible for a person to be healed by the power of his or her own mind?*
14. Do you enjoy reading fiction and getting involved in the stories?*
15. Do you enjoy watching tv/movies and getting involved in the stories?*
16. Are you basically a religious or spiritual person?*
17. Do you find talking about the supernatural fascinating?*
18. Are you able to sit or lie still for a period of time?*
19. While driving long distance, or driving a very familiar route, have you ever suddenly realized that you don't remember the previous 10-15 minutes of driving? As if your mind was somewhere else?*
20. If you were to imagine sucking on a sour, bitter, juicy, yellow lemon, would your mouth begin to water?*
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Thank you for submitting FORM # 2. Please complete FORM # 3 below.

FORM # 3

Client Bill of Rights for Hypnosis

This form must be completed before your appointment begins.

Contact Information:  My business name is Melissa Asteya, LLC. I can be contacted by telephone at (712) 301-2804, or through email at [email protected]

Education and Training:  I became a Certified Hypnotherapist in 2011 and a Certified Age, Womb, and Past Life Regression Hypnotherapist in 2014, both completed through the National Guild of Hypnotists. I complete annual continuing education to maintain my certification. In addition, I am a trained Professional Intuitive, Embody Love Coach, Certified Soul Realignment® Practitioner, Certified Karuna Reiki® Master Teacher and Certified Usui-Tibetan Reiki Master Teacher through the International Center for Reiki Training, and have a BA of Education from Buena Vista University.

Notice:  The state of South Dakota has not adopted any educational and training standards for the practice of hypnotism. This statement of credentials is for informational purposes only. Hypnotism is a self-regulating profession and state governments do not license its practitioners. I am neither a physician nor licensed health care provider and may not provide a medical diagnosis nor recommend discontinuances of medically prescribed treatments. If a client desires a diagnosis or any other type of treatment from a different practitioner, the client may seek such services at any time. In the event a client terminates my services, the client has a right to coordinate transfer of services to another practitioner. A client has a right to refuse hypnotism services at any time. A client has a right to be free of physical, verbal, or sexual abuse. A client has a right to know the expected duration of sessions, and may assert any right without retaliation.

Redress: I am a certified member of the National Guild of Hypnotists and practice in accordance with its code of Ethics and Standards. If you ever have a complaint about my Hypnosis services or behavior that I cannot resolve for you personally, you may contact the National Guild of Hypnotists at P.O. Box 308, Merrimack, NH 03054-0308, (603) 429-9438, to seek redress.

Fees: The charge for my private hypnotherapy services is dependent upon the type and length of session(s). All rates are available for your viewing on my website booking pages. All payments are due at time of booking and are non-refundable. I require 24 hours advance notice of any cancellation or change of appointment. Failure to do so will result in charges equivalent to one session fee. In home private parties & corporate events are also available for booking. Payment must also be made in advance for all group sessions. For info, please contact me via email.

Confidentiality: I will not release any information to anyone without a written authorization from you, except as provided for by law. You have a right to be allowed to access to our written record about you.

Insurance: I suggest you think of my services as something that you will pay for personally. That will both protect your privacy and help you value the work you are doing more. In general, insurance companies may not cover hypnotic services and I suggest you contact them directly.

My Mission: I am dedicated to assisting you through hypnosis and education in the effort to realize your goals, aspirations, and potential. Following suggested reinforcement techniques is imperative to your success. I firmly believe in the principle of mind over matter, or more simply put, “Where the mind goes, the body must follow.”

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Thank you for submitting FORM # 3. If you have completed and submitted all three forms, your paperwork is finished and I look forward to working with you!