Client Intake Form – Diane Edwards

Personal Appointment with Diane Edwards
Client Information Form

Please take a few minutes to complete this form, it will help me get to know a few things about you before our meeting.
I am sure there are many other things you would like to discuss, and there will be ample time in our session for this.

First Name

Last Name

Address

Occupation

Date of Birth

Phone Number

What would you like to accomplish in your session?

Have you ever used Hypnosis?

Are you taking Medication? If so, for what?

Any major changes in your life at this time?

Where did you get my name?

Your favorite place in nature?

Only for WEIGHT clients: What is your current weight?

What is your target weight?

When did you last weigh your target weight?

By sending this information, I understand that if I have any medical or mental problems, or under a Doctor’s care, or on any medication,
I will check with my Doctor BEFORE changing my regular diet, exercise habits or any life changes. I also understand that I am responsible
for my own behavior, and that going through this Hypnotherapy program does not guarantee success or refund.
THE INFORMATION ON THIS FORM IS STRICTLY CONFIDENTIAL

Personal Appointment with Diane EdwardsClient Information Form

Personal Appointment with Diane Edwards
Client Information Form