IF YOU ARE APPLYING FOR COVERAGE AS A HYPNOTHERAPIST, PLEASE ANSWER THE FOLLOWING QUESTIONS

(1) Do you hypnotize anyone for entertainment purposes? ( ) yes ( ) no

(2) Do you perform hypnosis as a form of anesthesia? ( ) yes ( ) no

(3) Do you provide any hands on therapy? (i.e. massage, Reiki, ( ) yes ( ) no
Hakomi, etc.)

(4) Do you provide past life regression therapy? ( ) yes ( ) no

If you have answered "Yes" to any of these questions, please submit in writing a detailed explanation of the services being offered.