Name
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First Name
Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
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Phone number you prefer to be reached at?
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Did someone refer you? If yes, please let us know their name so we can thank them. Please indicate if you do NOT want this person contacted.
How did you hear about Mama Soul Doc?
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Age
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Gender
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Profession/Work:
Marital Status
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Relationship History
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Emergency Contact
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First Name
Last Name
Phone Number
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Do you have thoughts of hurting yourself or taking your own life?
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List any current health matters of concern:
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Do you have a primary health care (GP) physician?
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What is your doctor's name and the name of their Clinic?
What is the address of their Clinic?
Have you discussed with your physician about hypnosis as an adjunct to your treatment?
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List any medications you are currently taking:
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Have you ever had any mental health treatment from a counselor, coach, therapist, or psychiatrist?
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Are you receiving mental health treatment now? Yes/No
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If yes, name of mental health professional:
If so, please give a brief history of your mental health treatment and the results of your treatment:
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What is currently your most important life goal or ambition?
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How long have you had this issue/problem(s)?
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Are you ready to make the changes necessary to address this goal?
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Please check any issue(s) that negatively influence you in any way? Check all applicable boxes
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Please provide more details on any of the issues you checked:
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Do you have any hobbies/activities that bring you joy?
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Briefly describe your spiritual/religious beliefs or life philosophy?
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What term do you use to refer to God?
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Please briefly share anything else that would be helpful to know about you?
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Terms & Conditions - Standard Consultations
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FEES & PAYMENT
Payment is due prior to your appointment by credit card, PayPal, or Interac. Credit card fees apply. If you wish to pay in installments, the schedule will be agreed upon in your WELCOME email. Failure to pay installments will result in the forfeiture of your visits.
CANCELLATION POLICY
Your time slot is reserved exclusively for you. Please arrive promptly (in-person or via Zoom) to obtain your full session.
A 24-hour cancellation notice is required, except in an emergency. If you must cancel or reschedule due to an emergency, please notify Dr. Alapin as soon as possible. If you do not arrive for your session and proper prior notice has not been given, you will be charged the entire fee for the session. Thank you for your consideration.
PREPAID SESSIONS
The above Cancellation Policy also applies to any programs with prepaid sessions. Failure to keep your appointment or non-emergency short-notice cancellations will result in the forfeiture of a prepaid session. No refunds will be given for unused prepaid sessions. All prepaid sessions are non-transferable and will expire after twelve months.
CONFIDENTIALITY
We will not release any client information to anyone without written authorization from you, except as provided for by law. Please see the confidentiality agreement.
MINORS
Appointments for children under the age of 18 require written consent from the parent or guardian via email to mamasouldoc@gmail.com. For optimal results, it is recommended that parents/guardians do not always accompany children during their sessions.
SAFETY
All youth and child sessions are video recorded for client and practitioner safety. These recordings are kept confidential and securely filed.
MEDICAL HYPNOSIS
Hypnosis is effective in relieving some medical conditions (e.g., pain management, migraines, IBS) but will require a signed release from your doctor or appropriate healthcare professional to avoid masking symptoms before proper diagnosis and/or medical treatment has been obtained. Non-medical issues (e.g., smoking, weight loss, confidence) will not require a form. Signing this form indicates that you understand that hypnosis is NOT a replacement for medical treatment, psychological or psychiatric services, or counseling. You also understand that the practitioner does not treat, prescribe for, or diagnose any condition.
RELEASE STATEMENT
I give my full consent to receiving sessions from Dr. Maya Alapin, Ph.D. for the purposes outlined in this intake form and for future purposes that I may request.
I understand that the success of my sessions depends greatly on my own ability and desire to affect change in myself. I understand that the results of my session(s) depend greatly upon my own serious participation and that Dr. Maya Alapin, Ph.D. cannot offer any guarantee of the success of my treatment. I am aware, however, that Dr. Maya Alapin, Ph.D. will do everything in her power to ensure my success and I agree to participate in each session to the best of my ability.
I hereby release Dr. Maya Alapin, Ph.D. from any liability.
I also understand that I have other choices from which to seek assistance regarding my specific concerns, and I have chosen Hypnosis at this time. I have been advised that I am free to terminate any or all sessions at any time. I have accurately provided background information as requested by Dr. Maya Alapin, Ph.D. I understand that during live sessions, the practitioner may touch me as part of the techniques. The practitioner will always advise of the location of the described touch and I hereby give my permission for such touch to take place when necessary. There is no physical touch via Zoom, and this does not inhibit the success of the sessions.
Scope of Work
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You have the right to refuse any aspect of Maya’s services and to seek services from another provider at any time. There are no refunds for services provided, and Maya does not guarantee specific outcomes or results.
The scope of work is defined by the problem you stated during your Discovery Call and in your WELCOME email. If you encounter a new, additional, or subsequent problem after your initial breakthrough, it will be considered a new issue. In this case, we will start the process again with a FREE Discovery Call and decide how to proceed from there.
Release of Liability Agreement:
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I personally know of no case on record where an individual has been harmed using these methods. I do know of thousands of cases
where people of all walks of life have benefitted greatly from the use of these methods. As a general practice, it is necessary for
everyone taking part in private sessions, classes, workshops, and seminars with Maya Alapin, to sign this Release of Liability
Agreement. Hypnosis practices are not the practice of Medicine or Psychotherapy, nor are they offered as a replacement for them.
Hypnosis is an Adjunctive Modality to other Medical or psychiatric treatments.
Agreement:
I am of legal age, and in consideration of my acceptance as a participant in this private hypnosis session, seminar, or workshop, I, for
myself, my heirs, my executors, administrators, and assignees, do hereby release and discharge Maya Alapin, Soulsway Hypnosis, from
all claims of damages arising from, or growing out of my participation in said activities. I agree that any claim of damages or disputes
arising from my participation in hypnosis sessions, seminars, workshops, or events, should it arise, shall be settled by binding
arbitration before an extra-judicial arbitration and mediation service selected by the parties.
To be more successful in reaching my goals, client agrees to:
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1. Be an active participant in my hypnosis experience and see myself as a partner in the transformative nature of this process.
2. Recognize that my thoughts, feelings, images, and actions have a direct effect on the quality of my life.
3. Acknowledge that my well-being depends directly on how well I care for myself physically, emotionally, intellectually, and
spiritually.
4. Accept that blaming others or myself is totally futile.
5. Take responsibility for my experience of life because I create my life experience to the best of my ability in the moment, with
what I know right now.
6. I agree to be on time for my sessions and allow at least 24 hours advance notice should I need to cancel or reschedule a
session.
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