- Tina Pineiro Life Solutions

Date

Name(Required)

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birthday

Occupation

Marital Status

Single

Married

Partner

Divorced

Separated

Children?

Email(Required)

Phone

Referred by

Reason for Appointment

Psychotherapy, counseling or alternative therapies you've received:

Describe Current Health

Do you sleep well?

Yes

History of seizures or epilepsy?

Yes

Have fears or phobias?

Yes

Current medications?

Are you in physical discomfort? If so, please describe.

If appropriate, may I consult your physician/therapist?

Yes

Please provide name, address, phone

Have you been hypnotized before?

Yes

Describe Your Expectation of Hypnosis

Describe a peaceful place for you.

Would you describe yourself as a spiritual person?

Is there anything else I should know to be helpful to you?

I understand that good and lasting results may require several hypnosis sessions, and that I may be required to practice self-hypnosis and/or listen to a reinforcement recording between sessions or at home. I am responsible for actively cooperating with, and participating in my program. Tina Pineiro, NGH Certified Consulting Hypnotist, shall not be held accountable for the results I attain. I understand that I may be referred elsewhere for proper treatment, and that my program may be terminated if deemed appropriate. I have read the client bill of rights, and I understand that all information about me will be kept strictly confidential.

Signature(Required)

Please type your name as digital consent.

Phone

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Client Intake Form