Client Intake & Consultation Form
Please take a moment to complete this form prior to our scheduled appointment.  If you need to cancel or reschedule for any reason, please do so by emailing me at myipwellness@gmail.com or leave a message at 239.444.1755.  Learn more about Rapid Transformational Therapy.  
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Email *
First & Last Name *
Date of Birth *
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Address *
Cell Phone *
Relationship Status *
Occupation 
Emergency Contact Name & Phone Number *
Doctor's Name & Phone Number *
Please List all Current Medications *
List Any Current Health Problems or Medical Conditions (present and past) *
Areas of Concern (check all that apply) *
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By clicking YES I agree and confirm that I have carefully read, fully understand, and voluntarily agree to all Terms and Conditions set forth by Inner Peace Wellness LLC. *
By clicking YES I agree to Inner Peace Wellness LLC cancellation and payment policy.  Appointments must be canceled or rescheduled at least X hours in advance or a cancellation fee may apply.  Payment of 50% is due upon scheduling your initial appointment with the remainder amount due XXXX.  No refunds will be provided for completed sessions.  *
By clicking YES I understand that my personal information and session details will remain confidential, except when disclosure is required by law (e.g. imminent harm to self and others). *
By clicking YES I understand that my personal information and session details will remain confidential, except when disclosure is required by law (e.g. imminent harm to self and others). *
By clicking YES I agree and recognize that hypnotherapy is not a substitute for traditional medical treatments or psychotherapy. The Hypnotherapist will work with the Client to ensure that their hypnotherapy sessions are integrated appropriately into their overall wellness plan, particularly if the Client is receiving other forms of treatment. Hypnotherapy does not guarantee specific outcomes, and progress will depend on the Client’s active participation and engagement in the process. The sessions are designed to of er support, insight, and emotional relief but should be part of a broader therapeutic or medical treatment plan when necessary. *
By clicking YES I agree consistency is essential for achieving meaningful progress in hypnotherapy. To ensure the best possible outcomes and maintain a productive therapeutic relationship, I agree to listen to the provided audio recording for at least 21 days in a row after my session. Adhering to the agreed-upon commitment to listen to the provided audio recording for at least 21 days consistently will maximize the benefits of hypnotherapy and support my transformation and success. *
By clicking YES I agree and confirm that I have carefully read, fully understand, and voluntarily agree to all terms and conditions. I acknowledge that I have had the opportunity to ask questions or seek clarification on any provisions within this agreement, and any concerns have been addressed to their satisfaction. *
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