Waiver/Contact Form

Intake Assessment

* Indicates required field

Name *

First

Last

Email: *

Phone Number *

DOB: *

Date: *

Age *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact *

Health Issues and Medications you're taking *

Phone Number *

Referral source *

Primary Objective *

In clicking this box I give permission for psychotherapy, hypnotherapy and breathwork practices... acknowledging that personal results vary without expressed or implied guarantees of results. I take full responsibility for my physical/emotional wellbeing and release Gloria Eichenauer harmless from any and all claims or liability arising from our sessions. Services are non-refundable and non transferable. I agree to paying for the session when failing to provide 24 hour courtesy notice of cancellation. I have carefully read the contraindications for the breathwork practice and take full response ability for my participation. I authorize RiseNshine and her constituents to photograph me during community events.
If under 18 years of age, clicking authorizes parental consent.

Choose Any *

I accept the terms and conditions

Submit

PSYCHO/HYPNOTHERAPY
Spiritual Counseling
CONTACT US
217-433-5759

My home
Scottsdale, AZ 85258
217-433-5759