I understand that I have entered into an agreement with David Gruben, of FRMS Hypnosis, for the sessions that I have booked with him at his office, or via Skype.

I have marked my sessions accurately in my calendar and understand that I will not receive a reminder call or notification prior to my session dates. (I will call to confirm dates if necessary.)

I understand that the time allotted for my sessions is reserved specifically for me, and a 24 hour notification for a cancelled or rescheduled appointment is necessary. If adequate notification is not given I will be charged for the session in full.

If area schools close due to weather conditions, I will not be charged for the session, however I must re-schedule another appointment at a suitable time, within 72 hours of the original appointment to replace the original appointment.

I may also opt to conduct my session via Skype over the internet. To utilize Skype I must have a computer that is equipped with a web-cam and have the program Skype downloaded on my computer prior to the scheduled appointment.


Client Name: ______________________________________________________

Date: ___________________________________________________________

Billing Address: ____________________________________________________

City: ______________________________________________ State:                   

Phone: ___________________________ E-mail:                                                    

Client’s Signature:                                                                                                     

Circle One: Visa, Master Card or American Express

Card #_______________________________________________________

Expiration Date:                                                       CV Code:                         

Name as it appears on the Card: ______________________________________________