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    Den Clare - The Hypnotherapy Consultancy

    CLIENT INTAKE & CONSENT FORM

    CONFIDENTIAL

    This intake form is to be completed and signed by all my new clients. The information you provide will become part of your confidential paper records, and will be destroyed within one year of your using my services. I keep no electronic records and do not share information. Once you have submitted this form I will contact you to schedule an appointment.

    What can I help you with?

    This part of the form allows you to tell me a little about the reasons you are asking for my help. Please include as much or as little information as you feel comfortable to share.

    You must put something in every box. So if the form does not send, check you have not left any empty.

    • Tel: (01983) 866999
    • denclare3@gmail.com
    • My Skype address: denclare3
    • Den Clare, 16 St Boniface Cliff Road, Shanklin, Isle of Wight. England PO37 6ET.

    This form is hosted by Pinkeye Graphics Ltd and provides a confidential service to submit information directly to Den Clare.  Your information is not viewed or retained by Pinkeye Graphics Ltd.  

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