Client Intake Form | Space Between Wellne

First name

Last name

Email

Phone

What would you like support with during your session?

What goals or changes would you like to experience through hypnotherapy?

Have you experienced hypnosis or hypnotherapy before?

Yes

No

Are you currently working with a medical or mental health professional?

Yes

No

Prefer not to say

Is there anything important you would like me to know before your session?

I understand that hypnotherapy is not a substitute for medical or psychological care and I take full responsibility for my participation in the session.

I have read and understand the Professional Disclosure & Client Agreement and consent to participate in hypnotherapy sessions.

Client Intake Form Before your session, please review the Professional Disclosure and Client Agreement. Professional Disclosure and Client Agreement

Client Intake Form
Before your session, please review the Professional Disclosure and Client Agreement.
Professional Disclosure and Client Agreement