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(Required) New Client Returning Client Date MM slash DD slash YYYY Full Name(Required) First Last Age Date of Birth(Required) MM slash DD slash YYYY Gender Occupation Preferred Name PhoneEmail(Required) Emergency Contact InformationEmergency Contact Name(Required) First Last Relationship Contact Phone Number(Required)Medical InformationGP (General Practitioner) Name: GP Phone NumberGP 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:Achieving goalsAnxietyCareerChildhood problemsConcentrationConfidenceCompulsive BehaviourDepressionDrinkingJob InterviewsMoneyExam StressEating DisordersFearsFertilityGamblingGuiltMotivationMemoryPain ControlPanicPhobiasNervesPublic SpeakingRelaxationSelf EsteemSleep ProblemsSkin ComplaintsSmokingStressRelationshipsWeight IssuesOther:Other DISCLAIMERPeople 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.DECLARATIONThe 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 CONSENTSignature(Required) Date(Required) MM slash DD slash YYYY 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.