VRishi Immersive Hypnotherapy

Application for Hypnotherapy Services

Jithendran Sellamuthu, C.MH. | AHA Cert 013165 | VRishi Hypno LLC

Personal Information

First Name

Last Name

Date of Birth

Are you over 18?

Yes No

Contact Information

Address

City

State

Zip

Home Phone

Cell Phone

Emergency Contact (Name and Phone)

Background

How did you hear about my services?

Have you been hypnotized before?

Yes No

If yes, by whom?

List any prescribed medications you are taking

Health Background

Are you currently, or have you ever been, under the care of a mental health therapist or counselor?

Being treated for any mental health conditions?

Yes No

If yes, please explain

Your Goals

What is the presenting issue you would like to work on?

How do you feel hypnotherapy can help you?

Is there anything else you would like me to know?

Client Signature (draw below)

Date

October 1, 2026

All information is confidential and will be used only for the purpose of preparing for your hypnotherapy sessions.