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Intake Sheet

Intake Sheet

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  • Date Format: MM slash DD slash YYYY
  • Signature:___________________________________________________Date:_________________________ GUARDIAN SIGNATURE (IF UNDER 18 YEARS OLD) _____________________________________________________________________________
  • I understand that good and lasting results may require several hypnosis sessions, and that I may be required to practice self-hypnosis and/or listen to a reinforcement recording between sessions or at home. I am responsible for actively cooperating with, and participating in my program. Tina Pineiro, NGH Certified Consulting Hypnotist, shall not be held accountable for the results I attain. I understand that I may be referred elsewhere for proper treatment, and that my program may be terminated if deemed appropriate. I have read the client bill of rights, and I understand that all information about me will be kept strictly confidential.