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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.

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!