Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone Number *

Country

(###)

###

####

Essential Health Information *

Please indicate if you suffer from any of the following conditions. I will be in touch to discuss in more detail.

Epilepsy

Psychosis

Not Applicable

Waiver *

I agree to my personal details being stored on a secure database.

Yes

Marketing *

I agree for Kintsugi Hypnotherapy to contact me via email with updates and news.

Yes

Consent *

I confirm that the information provided on this intake form is accurate to the best of my knowledge. I understand the importance of being truthful about my medical and personal history for the safety and effectiveness of the hypnotherapy session, any non- disclosure of information will be at my risk.

Yes