ReVIVE

1 Session

Please complete this form prior to booking your package. All Information is STRICTLY CONFIDENTIAL.

Name *

First

Last

Email *

Phone Number *

Reason you wish to receive hypnotherapy/hypnosis sessions: *

Have you tried hypnotherapy/hypnosis before? If so, for what? *

Waiver and Assumption of Risk: *

I certify that I am a competent adult and I take full responsibility for my results. I further agree that Robin Zamora assumes no responsibility for the outcome of the process and for guaranteeing its efficacy.
I do hereby waive and release any and all claims that may arise from the hypnosis sessions, acknowledging that this wavier and assumption of risk may not be revoked, altered, amended, rescinded or voided without prior written consent of Robin Zamora.
I voluntarily agree to undergo these hypnosis sessions with full understanding that Robin Zamora is not a medical doctor, nor a licensed mental health practitioner, and does not diagnose or treat any physical or mental disorders. I further understand that the hypnosis sessions are for educational and motivational purposes only. I understand that suggested reinforcement is only part of an educational and personal motivation program, which is solely informational, and not intended as medical or psychological advice in any form, which may only be given by a qualified medical or mental health professional.

Electronic Signature *

By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this client intake form.

Date *

Once you have successfully submitted your client intake form, please pay for your package below.

ReVIVE

Restore your connection to yourself, through deep relaxation and subconscious exploration. Together, we’ll uncover the solutions to fulfill your potential.

1 Session

$150

- ✔ One 60-minute session (phone or private video chat)
- ✔ Session focused entirely on your goal
- ✔ Mind Edit Client workbook to help you track your progress (PDF)

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