Hypnotherapy Hypnotherapy Utilize the power of your subconscious mind to promote healing, clarity, and behavior change. Inner Child Healing Hypnosis for Anxiety and Depression Vaping and Smoking Cessation Addiction Recovery Support Hypnosis for Anxiety and Depression Vaping and Smoking Cessation Addiction Recovery Support Weight Management Support Confidence and Self-Esteem Boosting Sleep and Insomnia Hypnosis Stress Reduction and Relaxation Hypnosis Hypnosis for Fears and Phobias (e.g., public speaking, flying) Spiritual Growth and Alignment Hypnosis Inner Child Healing Consult Now Hypnosis for Anxiety and Depression Consult Now Vaping and Smoking Cessation Consult Now Addiction Recovery Support Consult Now Weight Management Support Consult Now Confidence and Self-Esteem Boosting Consult Now Sleep and Insomnia Hypnosis Consult Now Stress Reduction and Relaxation Hypnosis Consult Now Hypnosis for Fears and Phobias (e.g., public speaking, flying) Consult Now Spiritual Growth and Alignment Hypnosis Consult Now Inner Child Healing Hypnosis for Anxiety and Depression Vaping and Smoking Cessation Addiction Recovery Support Hypnosis for Anxiety and Depression Vaping and Smoking Cessation Addiction Recovery Support Weight Management Support Confidence and Self-Esteem Boosting Sleep and Insomnia Hypnosis Stress Reduction and Relaxation Hypnosis Hypnosis for Fears and Phobias (e.g., public speaking, flying) Spiritual Growth and Alignment Hypnosis Trauma Healing and Inner Child Work Spiritual Awakening and Soul Purpose Exploration Anxiety, Insomnia, and Subconscious Rewiring 1. Client InformationFull NameDate of Birth MM slash DD slash YYYY Phone Number2. I authorize Mental Vitality Health PLLC to: Release information to Obtain information from Exchange information with 3. Recipient of InformationName/FacilityPhoneFaxAddress4. Information to Be Disclosed (check all that apply) Psychiatric evaluation Medication list Progress notes Treatment plan Diagnosis Medical history Lab results Other Other5. Purpose of Disclosure (check all that apply) Coordination of care Legal proceedings Insurance/benefits Personal use School/employment Other Other6. Authorization Terms I understand that this authorization is voluntary and that services will not be impacted if I choose not to sign. I understand that this authorization will remain in effect for one year from the date signed unless revoked earlier in writing. I understand I can revoke this authorization at any time in writing. Revocation does not apply to information already released in good faith. I understand that information disclosed may no longer be protected by HIPAA once it is released to a third party.7. Client Signature By signing below, I acknowledge that I have read and understand this authorization and voluntarily agree to the release of information as specified.Client SignatureDate MM slash DD slash YYYY Parent/Guardian (if minor)Relationship {{#message}}{{{message}}}{{/message}}{{^message}}Your submission failed. The server responded with {{status_text}} (code {{status_code}}). Please contact the developer of this form processor to improve this message. Learn More{{/message}}{{#message}}{{{message}}}{{/message}}{{^message}}It appears your submission was successful. Even though the server responded OK, it is possible the submission was not processed. Please contact the developer of this form processor to improve this message. Learn More{{/message}}Submitting…