Hypnotherapy Session Intake Form

Name *

Email Address *

Telephone Number *

Preferred session date *

Preferred session time *

For the following question, please take as long as you need and don’t worry if you can’t or don't want to answer some of them. Fill in as much or as little as you wish. All information is kept confidentially.

Description of the issue

Medical information (only if relevant to the session)

Other information

Please read our terms and conditions available here, as it contains important information regarding confidentiality, contra-indications and our cancellation/late attendance policy.

Terms and conditions

I have read and agree with the terms and conditions

Contraindications

I confirm I do not have any conditions listed in the contraindications section of the terms and conditions.

I have a condition listed but have my doctor's approval to engage in hypnotherapy.

Note:
For Zoom sessions, all the relevant details to join will be emailed to you once this booking has been confirmed.
For face-to-face sessions, you will receive a link to a Covid19 form you will be required to fill in before the session.

Hypnotherapy Session: £80