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ADVANCED HYPNOSIS - Canmore Hypnotherapy Client History Form

Please complete the form in full. You will be contacted with a range of convenient dates for your apointment.

Last Name *

First Name *

Age *

Sex *

Phone # *

Cell # *

Address *

Address 2

City *

Province *

Postal Code *

Country *

Email Address *

Marital Status *

Occupation

Reason for coming for Reiki - Hypnosis - Guided Imagery *

Any previous efforts to solve the problem *

Are you presently undergoing any Medical or Psychological treatment for the above problem *

Please indicate where you found my services *

Please select Agree or Disagree to indicate you agree or disagree with the statement linked to this form on the book appointment page. This is your electronic signature of agreement to that statement. *

Date *

Any other helpful comments *

Signed

Date

Witnessed

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