Client Information Form | Hai Tav Therapy

CLIENT INFORMATION FORM

First name

Last name

Birthday

Phone

Email

Address

Emergency Contact

Doctor

Health

Medication

Please Note: If you suffer/ed from any of the following hypnotherapy must be avoided as it may exacerbate symptoms:

From the list below tick any areas of concern:

Relationships

Childhood Problems

Socialising

Sexual Issues

I hereby confirm that the information I have provided on this form to Hai Tav Therapy for the purpose of RTT/RTC hypnotherapy/therapy/coaching is to the best of my knowledge, truthful and correct.

I have not deliberately withheld any information which may be dangerous to my mental health, or deter the process of therapy in any way.

I also declare that I am not suffering from any diagnosed psychiatric condition, psychological illness, or epilepsy, and I am not under the supervision of a psychiatrist or psychologist.

I promise to participate in all sessions free from the influence of any drugs or alcohol.

I understand that I should inform my therapist if I am prescribed any medication in the future for the duration of our therapy contract.

I understand and accept that the therapist may terminate the session without warning or refund if any of the above occurs or if she determines that the session has been booked for a purpose other than receiving therapy.

I understand that any therapy, coaching and recommendations by Haideh Tavackoli are not intended to replace the diagnosis or prescription of a medical doctor/GP. If in any doubt, please seek your doctor's advice.

Date

Signature