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PATIENT INTAKE FORM

So that I can add your to my list of patients, please provide the following information, answering the questions below and submit this online form to me BEFORE your first session.

Please note: The information you provide here is legally protected as confidential information.

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Have You Ever Been Hypnotized Before?
Do You Have or Have You Had Any Of The Following?
Are You On Any Medication Or Drugs?

Thanks for submitting!