Pittsburgh Life Coaching & Hypnotherapy                                                         Natalie Decker, PhD
                                                                                    
HOLISTIC LIFE & WELLNESS COACHING | HYPNOSIS | NLP  | GUIDED IMAGERY                                                                                   412-498-9421               

Book a Weight Loss Hypnosis Program

Book Weight Loss Hypnotherapy Session

Only use this form if you are actually signing up for the Weight Loss Program.  Otherwise, please use the general contact us form.

Please complete the form below and I will contact you shortly to complete your enrollment and to schedule your session/s.

First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code: (5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
How much weight would you like to lose?:
Why do you want to lose weight?:
Have you ever been hypnotized?:
How did you hear about us?:
Terms &Conditions:
TERMS AND CONDITIONS:

By submitting this form client has agreed to the following terms:

I understand that Natalie Decker, PhD, does not practice medicine, and does not diagnose or treat any medical condition. I affirm that I am not currently being treated for any medical condition related to my requested behavior modification program. Hypnosis can be used as a complementary care to most medical conditions; however a referral from your physician or licensed mental health counselor is required if requesting this type of hypnosis treatment. I also understand that hypnosis is not a replacement for traditional medical or mental treatment and should not be used as such. I understand that Hypnosis is not a replacement for my family doctors care nor is it to be used for, or is it a replacement for any medications, diagnosis or treatment of a licensed medical doctor.

I hereby authorize Natalie Decker to hypnotize me for the concerns we have discussed and/or that have indicated on this intake form. The form is confidential and is used only as a tool in helping develop an effective program for my individual needs. I give Natalie Decker permission to use hypnosis for any issues that have been outlined in this intake form and for any future purposes that I may request.

I understand that the success of my hypnosis sessions depends greatly on my own ability and desire to affect change in myself and the results depend greatly on my own serious participation and follow through. I understand that although hypnosis can be very effective and has a high success rate, Natalie Decker does not offer a guarantee, as my own personal success depends on my own ability and desire to create change in myself.

I authorize Natalie Decker to record our session and that the recording will remain strictly confidential between her and I. This recording will only be used for the purposes of her own personal reference or for liability protection if needed unless permission has other wise been attained by me (the client).

I understand that Natalie Decker does not accept any form of insurance or state supplied programs at this time and that my full payment is due at the time of our session via cash or credit/debit. 

*At least 24 hours’ notice is required prior to cancelling or rescheduling any appointment.  To ensure immediacy of my message, I will call at least 24 hours ahead of our appointment. While courtesy and mutual respect is always desirable, it is particularly important for hypnosis since rapport between client and practitioner is important to the success of my sessions. 
e’s time and I look forward to scheduling my next visit with her.


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