Registration form

HEALING YOUR MIND TO HELP YOU SHINE

Before we begin our hypnotherapy journey together, I ask that you complete the form below. Thank you!

Name

First Name

Last Name

Phone

(###)

###

####

Address

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

Emergency Contact Details

Please provide their Name, Phone Number, Email Address and Relationship to you.

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