Print and bring completed to our first session
Phone: Permission to vm:
Age: DOB: Marital status:
Emergency Contact: Phone:
Do you have a sense of what's blocking you:
Level of Distress (1-10):
I give permission for psychotherapy, hypnotherapy acknowledging that personal results vary and there are no expressed or implied guarantees of results. I agree to consult my health care practitioner for my medical care and the azbbhe.us to process complaints. I agree to a 24-hour cancellation notice or will pay the cost of the session. There are no refunds for services. I agree to my therapist’s discretion in outlining a treatment plan and method of execution. I have carefully read and agree to these terms of service.
I am responsible for covering the cost of the sessions.
Parental Consent if child is under 18:______________________
print and bring completed form to our first session