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Life Map Hypnosis with Tania Smith - Rainbow Lovina Healing Arts, LLC

RELEASE STATEMENT:

I hereby authorize Tania Smith to hypnotize me for the purposes outlined in this intake form and for future purposes that I may request. I understand that the success of my hypnosis therapy greatly depends on my own ability to affect change in myself. I understand that Tania cannot offer any guarantee of the success of my treatment. I am aware however, that Tania will do everything in her power to ensure my success and all information shared will remain confidential.

I also understand that I have other choices from which to seek assistance regarding my specific concerns, and have chosen hypnotherapy at this time.

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August 11, 2022 11:59 am CDT

Life Map Hypnosis with Tania Smith - Rainbow Lovina Healing Arts, LLC Uploaded by Tania Smith - Van Hoy - taniaspacegypsy@gmail.com IP 180.195.213.186