Transformative Hypnotherapy in Montreal: Heal & Thrive

Please complete both sections below. At the end, copy the message and send it by WhatsApp or Email.

Instructions
1) Fill out the Intake & Consultation Form (Step 1)
2) Complete and accept the Working Together Agreement (Step 2)
3) Copy the message and send it via WhatsApp or Email

Personal Details

Surname

Forename

Preferred Name

Date of Birth

Address

Relationship Status

Occupation

Email Address

Telephone Number

Emergency Contact Name

Emergency Contact Telephone

Health

Doctor’s Name and Address

Medication

Health Problems / Medical Conditions (Past & Current)

Areas of Concern (tick all that apply)

Tip: choose only what applies. You can discuss details during the consultation.

Additional Notes

Anything else you'd like us to know?

I confirm the information provided is accurate, and I consent to be contacted regarding this form.

Working Together Agreement
We have discussed, and both agree on, the nature of the therapeutic relationship and the principles, roles, expectations and working arrangements for the duration of the RTT® session or package.

Made between:

RTT® Therapist / Practitioner Name

Company Name

Client’s Name

Client’s Email

Date signed and agreed

Signed (Client)

Typing your name acts as your electronic signature.

I agree to the Privacy Policy

I agree to the Terms of Service

I agree to the Client Terms & Complaints

I have read and agree to the Disclaimer

Please complete the required fields in both steps and accept all checkboxes.

Message to copy & send

This message is prepared automatically from your answers to both steps.

Intake & Consultation Form + Working Together Agreement