Client Intake Form

MM slash DD slash YYYY
Marital Status
Do you sleep well?
History of seizures or epilepsy?
Have fears or phobias?
If appropriate, may I consult your physician/therapist?
Have you been hypnotized before?
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.
Please type your name as digital consent.
This field is for validation purposes and should be left unchanged.