Client Intake Form

Client Intake Form

Thank you in advance for taking the time to complete this form to help me get to know you better. If you are a new client, it is essential that you complete the questionnaire below, to allow me to get a complete picture of your lifestyle and history with hypnotherapy. I promise to use my skills to help you make the changes you are looking for and I will treat you with care and respect. I promise to give you my full professional attention during our sessions and promise to maintain strict confidentiality. I am professionally committed to using my education and skills to help you mobilize your own resources to achieve the results you seek.
Name(Required)
Address(Required)
Are you currently using drugs or other substances that alter consciousness and/or perception?(Required)
CLIENTS EXPRESS CONSENT(Required)
I understand that my success depends on my own commitment to improve my situation for what I came here for. I know that Sanela Covic does not prescribe or treat any physical and/or mental illness and I do not consider her responsible for them. I release you from any liability associated with my session. I agree to inform Sanela of any physical and/or mental illness that may affect her work with me. I understand that our sessions can result in healing. I authorize this form to be used for all future sessions. I agree to pay full compensation for each appointment canceled at least 48 hours in advance, excluding emergencies.
The information provided above and throughout the inquiry is/will be complete and correct to the best of my knowledge. *I understand that all information contained in this agreement and shared during treatment will remain confidential and will be used for therapy purposes only, except at times when the therapist believes there may be risk to me or someone else.(Required)
Data Protection(Required)
In order to comply with Regulation (EU) 2016/679 of the European Parliament and of the Council, of April 27, 2016, regarding the protection of natural persons with regard to the processing of personal data and the free circulation of these data, and following the Recommendations and Instructions issued by the Spanish Agency for Data Protection (A.E.P.D.), IT IS INFORMED: • The personal data requested and provided by you are incorporated into a privately owned file whose sole recipient and responsibility is Sanela Covic. • Only those data strictly necessary to adequately provide the requested services will be requested, and it may be necessary to collect contact information from third parties, such as legal representatives, guardians, or persons in charge designated by them. • All the data collected has a commitment to confidentiality, with the security measures established by law, and under no circumstances are they transferred or processed by third parties, physical or legal, without the prior consent of the client, guardian or legal representative, except in those cases in which it is essential for the correct provision of the service. • Once the relationship between the professional and the client has ended, the data will be archived and kept for a minimum period of 3 months, after which it will continue to be archived or, failing that, they will be returned in full to the client or legal authority. • The data I provide will be included in the Treatment called Clients of Sanela Covic, with the purpose of managing the contracted service, contact..., all procedures related to clients and I express my consent. I have also been informed of the possibility of exercising the rights of access, rectification, cancellation and opposition, indicating it in writing to Sanela Covic at sanela@sanelacovic.com.
¿Seguimos en contacto?(Required)
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