• Escape to Shanti Hypnotherapy Request Form

  • Personal Details:

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    Pick a Date
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  • Medical Details:

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  • Therapy goals:

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  • Client Declaration

    I declare that the information I have given is correct and as far as I am aware I  can undertake therapy without any adverse effects. I will promptly notify the therapist of any future changes to my health.

  • Clear
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    Pick a Date
  • Should be Empty:
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