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240 Roncesvalles Ave, Suite 5 Toronto, ON M6R 2L8
Phone: 647-773-8997
Email: info@hypnosis-toronto.com
www.hypnosis-toronto.com
Full Name:
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Address:
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City/Town:
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Postal Code:
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Email Address:
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Phone Number:
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Date Of Birth (DD/MM/YYYY):
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What are your medical conditions (past and present)?
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What height are you?
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What weight are you?
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Do you have any current back problems?
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If so, explain:
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Do you or have you ever had any mental or neurological disorders? If so, explain:
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What is your presenting problem?
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What would you like to achieve from our work together?
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What previous methods and/or treatments have you used in the past?
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Have you ever been hypnotized before?
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If so, what was your experience?
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What do you know about hypnosis? What do you believe hypnosis is?
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Is there anything else you feel I should know?
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How did you discover my service?
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How do you prefer to be contacted?
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Please be advised that you are expected to wear loose-fitting, comfortable clothing that is non-revealing.
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All fees are payable before each session by cash, cheque, or credit card.
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Terms & Conditions: Hypnosis is not and should never be a substitute for the advice of a medical doctor or any other health care practitioner. You, as a client, are always responsible for consulting your medical doctor, general practitioner and/or other health care professional(s) as appropriate to ensure your physical and mental well-being. If in doubt, you should contact your medical doctor before embarking on any complementary treatment.
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Confidentiality: We will not release any information to anyone without a written authorization from you, except as provided for by law.
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Safety: Sessions may be video recorded for the client and hypnotist's safety. These recordings are kept confidential and filed.
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