Please fill-out the following in-take form


The more information you're willing to share, the better we can help you.  The fields marked with a star ' * ' are required.  All information shared is held in strict confidence and will only be read by the practitioner of the VHHC whom you have chosen work with.

Personal Information

Please share the reason(s) why are you seeking psychotherapeutic help such as BMR and Hypnotherapy at this time?
What are your psychological and emotional patterns? Please list only the patterns having regular negative impact on your life:
Please list and/or describe any addiction or coping mechanism patterns you have:
Please list and/or describe any repeating circumstantial patterns in your life that you can think of:
Have you experienced trauma in your life? Please share below:
Please list below your most significant fears: (ie. fear of rejection, fear of loss, fear of abandonment, fear of failure/success, and so on)
Please describe below the known or suspected cause of the adjacent fear:
Have you been hypnotized before (as part of any previous hypnotherapy session or perhaps part of a stage hypnosis show)?

Here you can share any astrological / numerological / ayurvedic / chinese medicine information about yourself if you wish...
Personal health - past and present

What are your physical health concerns and challenges?
Self-Care
How did you hear about us?
I agree and consent to the services & procedures offered by Seamus Robertson, Holistic Therapist. I understand that the services & procedures included under the umbrella of Holistic Therapy include techniques & procedures from the following modalities: Shiatsu Therapy, Tui Na Massage, Cranio-Sacral, Cupping, Qi-Gong, Reiki, Lymphatic Drainage Massage, Active Release, Orthopaedic Assessments, Rebalancing, Polarity Therapy, Hakomi, Hypnotherapy, Bodytalk, & Taoist Massage. I understand and agree to the nature of these services and the techniques involved in them. I understand that if I have any questions about this information & the above services & procedures it is my responsibility to educate myself on them. I understand that by agreeing to all terms listed herein, I am giving informed consent to the services and procedures above. I proclaim that all of the information above is complete and accurate and will inform Mr. Robertson of any changes or updates immediately. I understand that any information shared during any treatment, health consultation, and coaching sessions must be accurate, whole, and complete. I understand that all information shared by Mr. Robertson is not in any way shape or form to be misconstrued for medical advice. I understand that I must consult with my Naturopathic Doctor, TCMD, GP, or Family Doctor before proceeding with any personal regiments or procedures (ie. diets, cleanses, supplementation, herbs, etc.) pertaining to any of the information shared by Mr. Robertson. I understand that I am free to withdraw my consent at any time. I understand that Mr. Robertson himself is free to end any session at any time for any inappropriate behaviour, poor hygiene, lack of compatibility between us as people, and/or health concerns that may immediately affect the clinic as a whole (ie. contractible diseases) and that full payment is required regardless of treatment completion. I understand that possible side effects of any treatment by Mr. Robertson can be: bruising, swelling, temporary pain or discomfort, nausea, vomiting, sweating, skin eruptions, dizziness, bad body odour, headaches, fatigue, and blurred vision. I agree to pay full treatment value for any future missed appointments or when less than 48 hours notice is given before any appointment cancellation or schedule changes. I understand that my submission of this form by clicking the 'send' button below applies as agreement to all of the above and as governance and consent to this current and all future therapy sessions, treatments, and appointments. I hereby release Mr. Robertson from any and all liability that may occur in connection with my receiving and/or my lack of understanding of the above aforementioned services & procedures.

I understand that experiencing the therapeutic techniques utilized within BMR and hypnosis are not guaranteed every appointment as it may become necessary to gather more information and/or discuss new developments that arise during the treatment. I understand that each session may run between 30 and 55 minutes and that the number of sessions required is variable. I also understand that results may not be evident until two or more sessions within at least one month have been completed. For best results, I understand that I should be prepared to explore whatever the therapy directs us to explore. I consent to my story being used for educational purposes and that identifying characteristics of me will be excluded. I understand that follow-up sessions are sometimes necessary.


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