EmailMe Form - Online Internet Session Information & Consent

Name *

First Last

Your Online ID (Skype, Messenger, Zoom, etc.) *

Email *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Date of Birth *

DD / MM / YYYY

Occupation *

Which service do you require? *

Clinical Hypnotherapy

Relationship Counselling

Please check one.

Reason for Session *

Have you had any previous Hypnotherapy or Counselling? *

Yes

No

If "Yes" please explain

Have you ever had a mental illness? *

Yes

No

If "Yes" please explain

Are you currently taking any medication? *

Yes

No

If "Yes" please explain

Are you currently receiving any treatment from any other health professional? *

Yes

No

If "Yes" please explain

Are you currently pregnant? *

Yes

No

Do you have Epilepsy? *

Yes

No

I have read and agree to the following:

Yes, I have read and do agree

1. I agree that all the information I have provided is correct.
2. I agree to be consulted by Grant Boddington. This consent applies until revoked in writing by me.
3. I agree that Grant Boddington shall not be held responsible or liable in any way, for any unforeseen outcome(s) from this, or any subsequent sessions that he conducts with me.
4. I agree to pay Grant Boddington the full fee for this, and any subsequent sessions that he conducts with me, prior to each session. (Please note that payment must be cleared before the session commences.)
5. I understand that there are no guarantees relating to the outcome(s) of this, or any subsequent Hypnotherapy or Counselling sessions, that Grant Boddington conducts with me - and that I may require more than one session.
6. I have read the Terms & Conditions