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New Client Form

New clients, please fill out this form before your first consultation. If you prefer a PDF document to print, visit out click here.

Date of Birth
Month
Day
Year
Have you ever been treated for an emotional problem?
Do you have an extreme fear of any of the following (please check all that apply):
Have you ever been diagnosed with (please check all that apply):

Terms:


I realize that Angie Hitz is a certified Clinical Hypnotist. She is not a medical doctor, and she cannot diagnose disease, prescribe, or treat medical conditions or serious disorders.


I understand that the hypnosis coaching and training I am receiving from Angie Hitz is not a substitute for normal medical care and I have been advised to discuss this procedure with any doctor who is taking care of me now or in the future.


Additionally, I should continue any present medical treatment and consult my regular physician for treatment of any new or old illnesses. I am willing to be guided through various methods including relaxation, visual imagery, creative visualization, hypnosis, NLP, mind scaping, parts work (ego state), emotional freedom techniques (EFT) and stress reduction processes for the purposes of vocational or avocational self-improvement.


I also agree that Angie Hitz, or myself, may terminate this relationship at any time for any reason whatsoever.


I realize that although Angie Hitz has training and experience, the training and insight she provides are not a cure and I accept that I am attending meetings for her time, expertise, and insights irrespective of any particular result.


Angie Hitz will not share my information with anyone without my permission, except as provided for by law.


As a service, Angie Hitz may make audio recordings for my use. Since such recordings include instructions for relaxation, I agree not to play/listen to any hypnosis recordings in a moving vehicle, whether I am driving or not, or when I am providing direct supervision to a small child or an incapacitated adult. I agree that any recordings are for my personal use, and that if I allow others to listen to it/them that Angie Hitz with Levitate Wellness is not responsible for the outcomes or results for others.


I agree to notify Angie Hitz a minimum of 24 hours in advance of an appointment if I need to cancel or rearrange. Failing to do so may incur a cancelation fee of 50% of the session cost.


I agree to the payment of $85 per session, payable on or before the day of service, which will be approximately 60 to 90 minutes in duration.

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Month
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