Intake Assessment (Please Print and bring with you to first session)
Name: _____________________________________________ Date: ________________
Phone: ________________________________ Permission to message/email you: Y/N
Age: ___________ DOB: ________________ Marital Status: _____________________
Emergency Contact: ___________________________ Phone: ______________________
Employment: ____________________________________ Job Satisfaction:___________
Primary objective: ____________________________________________________________
Motivation for change: ________________________________________________________
What is blocking you: _________________________________________________________
Health Issues: _________________________________________________________________
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 with my therapist’s discretion in outlining a treatment plan and method of execution.
There are no refunds for services.
I agree to a 24-hour cancellation notice or will pay the cost of the session. I am responsible for covering the cost of the sessions.
I have carefully read and agree to these terms of service.
Parental Consent if child is under 18: _________________________________________