NEW CLIENT FORM

Name *
Name
Phone 1
Phone 1
Date of Birth
Date of Birth
include City, State, & Zip Code
Marital Status
Name of close friend/relative to contact in case of emergency
Name of close friend/relative to contact in case of emergency
Their phone number
Their phone number
Have you been hypnotized before?
Preferred method of communication
Check all that apply
Would you like appointment reminders?
If yes, how?
Check all that apply