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Client Information and Participation Agreement
Client Hypnotherapy Intake Form
Client Information and Participation Agreement This information will be used to aid in serving you as the client. Please answer honestly and know that answer yes or no to any particular question does not mean that you cannot receive services from this practitioner. Your honest answers serve in your receipt of appropriate care and services. All information will be kept confidential with the Accountability Act (HIPAA) regulations.
First Name
*
Last Name
*
Street Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone Number
*
Is it ok to leave a message and text to this number?
*
Yes
No
Other
Other
Email Address
*
Is it ok to email this address?
*
Yes
No
Other
Other
Date of birth:
*
+
Age
*
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Tanya Fuller, Hypnotherapist, CMS-CHt, FIBH