Release.Realign.Rise

It is time to become who you were born to be

Intake Form

First name

Last name

Phone

Birthday

Month

Day

Year

Address

Emergency Contact - Name

Emergency Contact - Phone Number

Are you presently in treatment for any condition(s)?

Yes

If YES, please provide a brief description of the condition(s)

Are you currently taking any medication?

Yes

If YES, please indicate the medication and the reason why

Doctor's name ands phone number for consultation and follow up, if applicable

Reason for the visit - what's your goal?

What are your expectations from our work together?

I hereby state that (choose one)

Disclosure Consent

Andrea Correia does not treat, prescribe for, or diagnose any condition. She is a properly trained and certified hypnotherapist and is not practicing any other profession that requires a license under the laws and regulations of the State of Florida. Hypnosis is not a substitute for medical or psychological treatment. Hypnosis for subclinical purposes requires no referral. She only practices therapeutic hypnosis within the guidelines of the law and Florida Statute 485, which requires a referral and oversight from a licensed practitioner of the healing arts. By signing below, I state that I have read and understand this Disclosure and give Consent to be hypnotized for the purpose of helping me to accomplish the goal(s) I have described above. If I am scheduling multiple sessions, I understand that I will be charged for any session cancelled with less than 24-hour notification. I understand that Andrea Correia offers no refunds and only credit for any unused portion of any multi-session program. I further give permission for Andrea Correia to record my session and to discuss my case with my physician, if appropriate.

Your signature

By typing my name, I'm confirming my agreement, just as if I had signed in person.

Today's Date

Month

Day

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