Janis Jarvis Welcomes You to Hypnotherapy by the Bay, LLC -
This page has all the information and an easy on-line intake form (optional) that you may complete before you arrive for your appointment. 

 First let's make an appointment

Your Hypnotherapy by the Bay Appointment
Which day would you like to select?
Which time would be your first choice?
Hours
 
 : 
Minutes
 
First Name
Last Name
Would you prefer your confirmation by text, email or phone?
Phone Number
Email Address
Professional Courtesy and Client Safeguarding

 1. If  you have been diagnosed with any of the following conditions, I must have a doctor’s written permission to proceed with your hypnosis session:

____Schizophrenia ____Chronic Depression ____Bi-polar ____
Heart Disease ____Epilepsy

2.  If you are already seeing a health or wellness professional for assistance with the goal for which you are seeking hypnosis, as a matter of courtesy and to enhance your care, please advise them of your intention to undergo hypnosis; and bring a note from them advising me that they are aware of your intention and that to the best of their knowledge there is no reason why you should not be hypnotized.   

For your convenience, you may use the following form:

Dr or therapist form.pdf (PDF — 19 KB)
If neither 1. or 2. apply to you, you are ready to proceed to the next step.

Intake

Optional On-Line Process

You may help me automate this process by filling this out on-line right here before your first appointment.  This is a secure website and I keep my computer secured with a password and of course my files locked.  However, I cannot guarantee that this website will not be hacked or that someone at Vistaprint may get access to your information.  So, if you prefer to provide some or all of this information in the office or via email before your visit, I absolutely understand your concern.  Or, 

Download the form here and bring it with you:

Intake01032018.pdf (PDF — 35 KB)
If you would prefer to do it now, please provide as much information below as you are comfortable sharing on-line, knowing that even though I expect it to remain confidential I cannot promise that no one else may see it besides me. 

We will go over it in the office so you can provide further details then.

Thanks so much.  

Janis Jarvis
410-212-4144
janiskcjarvis@hypnobythebay.com



First Name
Last Name
Phone Number
Email addres
Birthday
Age
How did you hear about us?
What would you like to use hypnotherapy to address?
Previous efforts to address this goal.
Have you ever undergone hypnosis before? If so, please describe.
Have you been under physical or psychological treatment within the past year? If so, please describe?
Do you consume any mood altering drugs? If so, please describe.
Do you have any allergies? If so, please list them.
What else would you like to address using hypnotherapy in future sessions?
Would you like a Soul Link session?
Would you like a Professional Life Coaching Package? 4 or 6 weeks?
Thank You for scrolling so far and sending me information about you! I value your time and trust.

Looking forward to seeing YOU soon! 
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