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Client Questionnaire

Client QuestionnaireSHAdmin2020-04-08T23:53:46+00:00

Step 1 of 6

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  • GENERAL CLIENT INFORMATION

    Items with an * are required.
  • I, the undersigned, having requested a consultation for hypnotherapy, understand that hypnotherapy is a conditioning process, whereby an individual is taught to use their own abilities, for their own lasting results. I understand that personal results vary. Further, I am aware that hypnotherapy is non-medical, and agree to consult my personal doctor for medical advice and/or treatment.

    I realize that missed appointments, without 24 hours notice, will be fully chargeable to me at regular rates.

    I understand that I am responsible for the results of my hypnotherapy, and that all payments, for past, current, or future sessions, are non-refundable.

    I also understand that all information is strictly confidential.
  • MM slash DD slash YYYY
  • UNWANTED EMOTIONS

  • DO YOU HAVE A HISTORY OF:

  • HABITS

  • PHYSICAL PAIN

  • PERSONAL ISSUES

  • INSOMNIA

  • DESIRED EMOTIONS THAT ARE ABSENT

  • WEIGHT

  • RELATIONSHIPS

  • PROFESSIONAL

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