Patient Intake

Name

First

Last

Phone

Email

Birth Date

Social Security Number

Address

City

State/Province

Zip/Postal

Country

Which areas do you feel you need help with?

Have you ever been diagnosed with any of the following?

Have you ever been hypnotized?

Yes

No

Not Sure

Please read in full prior to signing:

I have answered the prior questions as accurately as possible and understand that my progress is directly related to my participation and absolute honesty in any therapeutic actions recommended for my case.

I also understand that various modalities will be utilized depending on my individual needs including, but not limited to hypnotherapy and cognitive behavioral therapy.

Dr Gary Danko and Quantum Life Repair do not make medical claims, nor do we have the ability to guarantee any certain result because results are dependent on the participation of both the client and the therapist.

There are no refunds on services rendered, nor on deposits for such services as those deposits hold placement in our schedule that could otherwise be filled with other appointments.

Electronic Signature

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