Name: _____________________________________________ Date: __________
Permission to leave messages and email you: Y/N
Age: ___________ DOB: ________________ Marital status: ________________
Emergency Contact: ___________________________ phone: ______________________
Employment: ____________________________________ Stress level: ____________
Insurance: __________________________ Direct Pay: _______________________________
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 to a 24-hour cancellation notice or will pay the cost of the session. There are no refunds for services. I further agree with 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: ______________________________________________