Waiver/Contact Form

Intake Assessment

* Indicates required field

Name *

First

Last

Age: *

Phone Number *

DOB: *

Date: *

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Emergency Contact *

Phone Number *

Primary Objective *

Health Issues and Medications you're taking *

Referral source *

By clicking this box I give permission for psychotherapy, hypnotherapy and breathwork practices acknowledging that personal results vary and there are no expressed or implied guarantees of results. I take full responsibility for my physical and emotional wellbeing and hereby release and hold Gloria Eichenauer harmless from any and all claims or liability arising from or in connection with my sessions. There are no refunds for services. I have carefully read through the contraindications for the breathwork practice and in checking the box below take full response ability for my participation. I further authorize RiseNshine and her constituents to photograph me during class and community events.
If under 18 years of age, clicking confirms parental consent has been authorized. I have carefully read and agree to these terms of service.

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