client information form


 
PERSONAL INFORMATION
Name *
Name
Full Address *
Full Address
Home Phone
Home Phone
Business Phone
Business Phone
Mobile Phone *
Mobile Phone
Date of Birth *
Date of Birth
SYMPTOMATOLOGY
MEDICAL HISTORY
Doctor's Name
Doctor's Name
Doctor's Address
Doctor's Address
Doctor Telephone
Doctor Telephone
TREATMENT GOALS
CLIENT INFORMED CONSENT
DISCLAIMER *
Please note that any cancellations require a minimum of 24 hours notice, or you will be invoiced for the full session. In my experience most clients who follow my advice, experience excellent results in a couple of sessions. The first session is $150. As indicated elsewhere on this form I require this form to be submitted prior to appointments to ensure that time is used to best effect. It's important to remember that no therapist or practitioner can guarantee total success, but be assured that you will always receive my best attention at all times I understand that while David Ashkenazy is a Certified and Registered Hypnotist, he is not a doctor, psychotherapist, psychiatrist, or social worker and has never represented himself to me as anything other than a Practitioner of Hypnosis. I enter into treatment with him freely and with the above understanding. I accept that results are not guaranteed and that I will cooperate fully in the treatment program to the extent that my own values dictate.