Impactful Today Ltd
Confidential and secure client intake form
About you
About you
Let's get to know you a little better
Name
*
First Name
Last Name
Date of birth
*
Email
*
example@example.com
Is there any part of your past that you do not want to explore (certain ages or experiences)
*
Emergency contact
*
First Name
Last Name
Emergency contact phone
*
Your medical history
Your medical history
Do you suffer from Asthma or allergies?
*
Yes
No
Have you ever suffered from depression?
*
Yes
No
Have you ever suffered from epilepsy in the last two years?
*
Yes
No
Have you been diagnosed with any form of psychosis or multiple personality disorder?
*
Yes
No
Have you ever had treatment from any of the following: Psychologist, Psychiatrist or Hypnotist?
*
Yes
No
If yes please advise what was covered/ prescribed
*
Are you taking any drugs or medication at present?
*
Doctor's name
*
First Name
Last Name
Doctor's address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Doctor's telephone number
*
The legal stuff
I have been advised of the scope of hypnotherapy practice and I give my full consent to receiving hypnotherapy sessions.
*
Yes
I have read and understand the privacy policy, T&C's, cancellation policy and disclaimer
*
Yes
I have agreed to participate in each session to the best of my ability.
*
Yes
I have accurately provided background information as requested by the practitioner and confirm that I have no conditions that mean hypnosis in contraindicated.
*
Yes
I understand that confidentially regarding my sessions will be honored unless the practitioner feels that I or someone else are in danger, in which case disclosures will be kept to a bare minimum necessary for my protection or the protection of a third party.
*
Yes
Accepting terms
Please sign below to confirm acceptance of terms and then click submit.
I confirm that I have understood and accept all of the above terms including disclaimer. I have provided correct and factual information.
*
Submit
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