Live a life you love.

Current Clients

CLIENT INTAKE FORM

To book additional sessions:

Complete the Client Intake Form.
Email [email protected] if you have any difficulties.

Client Intake Form

General Information

New Client

Returning Client

Date

Full Name(Required)

Age

Date of Birth(Required)

Gender

Occupation

Preferred Name

Phone

Email(Required)

Emergency Contact Information

Emergency Contact Name(Required)

Relationship

Contact Phone Number(Required)

Medical Information

GP (General Practitioner) Name:

GP Phone Number

GP Address

Are you currently receiving any treatment from a Doctor or other Practitioner? If yes, please give brief details:(Required)

Are you currently taking any medication? If yes, please give details:(Required)

Please give a brief background of your current concern:(Required)

What do you wish to receive from your session?(Required)

From the list below, check all that apply:

Other

DISCLAIMER

People with Epilepsy or any person diagnosed as having a psychotic illness should not enter hypnosis. Shushan Aleaqui accepts no responsibility whatsoever. Under no circumstances including but not limited to negligence shall Shushan Aleaqui be liable for any special or consequential damages in any way whatsoever now or in the future that result from the use of or the inability to use hypnosis, advanced hypnotic techniques, hypnotherapy or any other therapies. The information, techniques, methods and recommendations by Shushan Aleaqui are not intended to substitute for the diagnosis and a care of a qualified doctor nor to encourage the treatment of illness by persons not recognizably qualified. If you use hypnosis and are under medical care for any condition, do not make any adjustments to any prescribed medication without the approval of your doctor. If in any doubt, you should seek medical advice. Shushan Aleaqui has taken due care and attention with the information provided at this therapy session and information is given in good faith. The information given is not intended to constitute medical advice. Always consult your GP before changing medications and evaluating treatment alternatives. Shushan Aleaqui does not accept responsibility for any loss, damage or expense resulting from the use of information provided. You agree to indemnify and hold us harmless by signing and agreeing to these conditions.

DECLARATION

The information I have given here is to the best of my knowledge, full and correct. I undertake therapy on the understanding that it is a collaborative process, and that progress depends in part upon my own motivation and participation.

I accept that all appointments not canceled with 48 hours will be charged in full.(Required)

I accept

CONSENT

Signature(Required)

Date(Required)

Method of Payment(Required)

PayPal ([email protected])

Zelle (2123210489)

Venmo (@shushan-aleaqui)

Credit Card: If you wish to pay by credit card, you can do so by phone prior to the scheduled session.
Payment must be received prior to session.

Contact: [email protected] // www.RapidLifeTherapy.com
Zoom link will be sent once the appointment date and time is confirmed.

You deserve the freedom you'll find.

Achieving goals
Anxiety
Career
Childhood problems
Concentration
Confidence
Compulsive Behaviour
Depression
Drinking
Job Interviews
Money
Exam Stress
Eating Disorders
Fears
Fertility
Gambling
Guilt
Motivation
Memory
Pain Control
Panic
Phobias
Nerves
Public Speaking
Relaxation
Self Esteem
Sleep Problems
Skin Complaints
Smoking
Stress
Relationships
Weight Issues
Other: