Client Consent Form Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Mobile number * (###) ### #### GP Practice Details * Please provide details of any medication you are taking I have read the Coast Hypnotherapy Privacy Policy and I am aware of how my data will be processed and stored * Yes No I consent to Coast Hypnotherapy contacting my GP * Yes No I consent to receiving Solution Focused Hypnotherapy from Coast Hypnotherapy * Yes No I have read and agree to the Coast Hypnotherapy Terms of Business and accept treatment on those terms * Yes No I understand that the success of the treatment is in part determined by the client's desire to achieve the changes and their commitment to the format of the sessions (including listening to the relaxation track as directed) * Yes No I understand that the fee payable is non-refundable and that a minimum of 48 hours' notice is required to reschedule a session * Yes No I understand that I have the right to ask questions and to discontinue the treatment at any time * Yes No Date * MM DD YYYY Thank you!