Before we get started, why are you completing this Online Intake?

Let's Establish Your Legal Authority to Complete this Intake.    

- Are you the New Client, or are you completing this Intake for someone else? 

- If the New Client is someone else, what is your legal role for them? 

• For a minor child or adult ward, we must have a separate Parental or Custodial Consent before the first appointment. We'll send you the form and discuss the details with you later. 

• If you're completing this Intake for someone else who is a legally competent adult, please stop here.  Legally competent adults, unless physically unable, are responsible for completing their own Online Intake Assessment.  Thank you! 

Contact Information for Parent or Legal Guardian:  If you're the adult with legal authority to complete this Intake and give consent for a minor child or adult ward, please enter your contact information: 

• Phone number(s) - In the United States please use this format:  xxx-xxx-xxxx. If you're outside the United States, please include your country code.)

• Email address

• Mailing address - Please put your address in the format that would be used to send you a letter or package, including postal code and country, if necessary. 

If this question does not apply to you, please put "Does not apply" or "N/A".

What's your full name?  (Please use this format: First Middle Last)

What's your date of birth?  Please use this format:  MM/DD/YYYY

What telephone number(s) should we use to reach you? 

• Please include your area code (and country code if outside the United States)

• Please label your number(s) as Mobile, Landline, Home, Work, a Friend's. 

If you are not the client (because you're a parent or guardian and completing this Intake for someone else), what email address should we use for the client? You will enter your own email address at the very end of this Intake as the person giving Electronic Consent. 

What is your mailing address for physical mail?  Please enter your address as you would use it to send a letter or package to yourself, including apartment, box number, city, state or province, country and zip or postal code.

What is your present occupation?  If you're not currently engaged in that occupation, what is your usual occupation?  What do you usually do with most of your time? 

What is the highest level of education that you've completed so far?  (No judgment here. Education does not necessarily equal intelligence or ability! We just ask to understand your situation better.) 

Who's most important in your life?  This might be your spouse, romantic partner, family member, friend or someone else you may refer to in your sessions. Please state your relationship with them. 

We will not share information with them about you without a signed Release of Information from you. We'll get you the form upon your request. 

We'll ask about who you want to list as your emergency contact next.  

Who should we contact in case of an emergency? Please provide us with their full name, their relationship to you, their best phone number and their email address. This person can be someone different from the person (or people) you listed above.

We will not contact this person except in case of emergency, or unless you specifically ask us to do so. 

In your own words, what are your goals for your Hypnotherapy / EFT sessions?  What are you hoping to accomplish or create for yourself? 

The Scope of Hypnotherapy Practice 

(a) The general scope of Hypnotherapy practice includes vocational and avocational goals and self-improvement. 

(b) Issues and goals that involve a mental health or medical health nature, component or origin are treated in Hypnotherapy through licensed mental health or medical referrals only, in accordance with the Hypnotherapists' Code of Ethics.

(c) Furthermore, there are no guarantees as to the results or progress to be made, only that the Hypnotherapist will, to the best of their ability, endeavor to accomplish the objective(s) of my sessions.

For more information, please see section "I. Disclosure of Services" in our Terms of Service.

Some goals and issues require a Healthcare Referral from a Licensed Provider.  

Do any of the following apply to you?

• One or more of your goals relates to a medical, dental or mental health issue. 

• You're a female and want to lose 25 pounds or more overall. 

• You're a male and want to lose 35 pounds or more overall. 

• You're not sure if your goal will require a Healthcare Referral. 

If any of the above applies to you, you may need a Healthcare Referral.  

• Getting your referral is relatively easy. 

• After you finish this Intake, just go back to Step 2 on this page and download the Healthcare Referral Instructions and Form (PDF) with everything you need. 

•  You may have your first session without a Healthcare Referral as we create a plan for achieving your goals. 

•  Please be sure to send us your Healthcare Referral from your Licensed Provider before your second session.

Please select your answer below to continue your Intake. 

Are you a military veteran or active duty military now? 

Veterans and active duty military personnel qualify for a 10% discount off public pricing for Private Hypnotherapy Sessions. Proof of service may be required.

Silver Membership in Positively H.U.B. Has Its Perks

You can maximize your savings, get access to two weekly group sessions to help you create your next breakthrough, and qualify for discounts plus needs-based a "sliding scale" if you need it for our Hypnotherapy Programs, all for a surprisingly low monthly subscription. Please refer to the Terms of Service for the most up-to-date information on Silver Members-only discounts and benefits. (Seriously! Go read it!)

We offer monthly membership for two reasons:

1) For you: To maximize your savings and your breakthroughs and offer you more benefits.

2) For us: To maximize our efforts to serve you and to make our services more accessible and affordable for more people. 

To explore your membership options, please visit https://positively-hub.com

If you are participating in one of our Weight Loss Hypnosis Programs, please choose the Weight Loss Hypnosis Program that is best for you below. 

Remember: you qualify for a discount if you are a paying Silver Member of Positively H.U.B.  Ask for your Coupon Code to use during Checkout for your Weight Loss Hypnosis Program. If you're not a Member yet and would like to join, please go here:  https://positively-hub.com/join 

If you are not going to do a Weight Loss Hypnosis Program at this time, please select "E - This question doesn't apply to me."

Additional Terms of Service apply.  Please refer to our Terms of Service.

ADDITIONAL CONDITIONS 

The space below is for any Additional Conditions to be included in the agreement between you and Transformation Roadtrip LLC.  

Please follow any instructions we may have provided you for this space. 

DECLARATION OF CONSENT:

1. I have read and understood these Terms of Service including the Disclosure of Services and Acknowledgment of Fees and Services. I have also read Jackie Ambrow's Biography and Training. 

2. I accept the Terms of Service and and I agree that, by entering my name and email at the end of this Online Intake assessment, I am giving my Electronic Consent in lieu of my physical signature effective the date of this completed assessment.

3. I agree and understand that the Terms of Service may be updated from time to time and that my continued participation indicates that I accept any update. 

4. I agree and affirm that I am competent and of legal age to enter into this agreement. I agree that any legal dispute arising out of this agreement will be resolved according to the laws of the State of Texas.

5. I agree and affirm that I will do my best to resolve any dispute with integrity on my part and in a direct, friendly, respectful, honest and prompt manner, and I understand that you will do the same!