REGISTRATION FORM – Online Therapy Sessions

REGISTRATION FORM - Online Therapy Sessions

Name*
First Last
Email*
Phone*
Date of Birth*
Address*
Street Address City ZIP / Postal Code Country
Social Media Link / Facebook Link*
Have you been previously taken any Coaching Session or therapies through Hypnosis/ NLP / Psychotherapies or any other modality?*
Please describe any personal conditions including current medications, relevant medical history including neck/ back/shoulder issues, serious allergies, trauma, or mental health diagnoses:*
Tick if you have any of the following conditions?
- Epilepsy
- Light Senstivity
- Pregnant
- Using a Pacemaker
- None
You were referred by whom? or How did you come to know about us?
The people you live with and their roles in your life:*
What's your Profession? Does your present work satisfy you? And if not, in what ways are you dissatisfied?*
Please write the specific problems for which you want therapy/change-work? Since how many years are you having each problem in your life?*
And lastly, what do you expect from me as your Therapist, Coach & Trainer, from our sessions together? What are your Outcomes that you want to achieve?*
Consent*
I agree that any and all recordings or written materials included or presented as part of this program are the property of ‘Surili Heals’, and may not be used without prior written permission.

As a Client/ Coachee, I agree that the sessions may be recorded or videotaped with the intention of keeping the track records and evidence.

I also agree that I will not record the session or program, or any part thereof. No individual audio recording is allowed.

I agree that I am a healthy and stable individual, and that I do not have any current medical or psychological conditions which would in any way impair my functions in this training, or disrupt the positive experience of the other participants.

I agree that if I am taking any form of prescribed medication that I will continue to take this medication throughout the sessions and will not discontinue its use during the sessions.

I agree that I will not be under the influence of any other drugs or alcohol during the time of any session. If I come to the session in an intoxicated state, I understand that I will be asked to leave the sessions and will agree to do so.

I agree that these sessions are not a substitute for on-going psychiatry or psychotherapies.

I hereby agree and request to be subjected to altered state, or to the use of other mental techniques. I acknowledge that these processes present a potentially powerful emotional, mental and physical regulating patterns, tools and techniques.

I understand that personal results will vary and there are no expressed or implied guarantees or warranties of results.

I am aware that this program is non-medical in nature and for any changes in medications or medical questions or needs, I will consult my health care practitioner.

I understand that some of the mental processes used can bring up unconscious memories, images or metaphor.

Refund policy: If you drop the session from the mentioned schedule, no session fee will be returned or refunded.

Attendance/Continuity Policy: It is highly recommended to continue/attend the required number of sessions, as suggested by the Therapist/Coach.

I understand that confidentiality regarding my sessions will be honored between me and my therapist/Coach.
I agree to the Ethics Agreement as detailed above:
Place*
Date of Acceptance*
Name
This field is for validation purposes and should be left unchanged.

REGISTRATION FORM – Online Therapy Sessions

REGISTRATION FORM - Online Therapy Sessions

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