Online Intake Form | Sudbury Hypnosis

Name *

First

Last

Date of Birth *

Email *

Address *

Telephone *

Marital Status

Number of Children

Occupation

Hobbies/Interests

What do you hope to accomplish with hypnosis/hypnotherapy?

Is there any part of your past that you do not want to explore? (Certain ages or experiences)

What do you hope to accomplish with hypnosis/hypnotherapy?

Other Fears/Phobias

Compulsive Habits

Do you suffer from asthma/allergies?

Have you ever suffered from depression? *

Have you suffered from epilepsy in the last two years? *

Have you ever had treatment from a psychologist/psychiatrist/hypnotist? (if yes, please give brief details)

Have you had hypnosis before?

Where did you hear of Sudbury Hypnosis?

Current state of health?

Are you currently taking any drugs/medication?

Details of major operations

Doctors name and address

I have been advised of the scope of hypnosis/hypnotherapy practice and I give my full consent to receiving hypnosis/hypnotherapy sessions. *

Yes
No

I understand that results vary and that the practitioner may not guarantee results. *

Yes
No

Hypnosis/Hypnotherapy is not a replacement for medical treatment, psychological or psychiatric services or counselling. *

Yes
No

I understand that the practitioner does not treat, prescribe for or diagnose any condition. *

Yes
No

I understand that the practitioner is a facilitator of hypnosis or hypnotherapy and is not practicing any other profession that requires a license under the laws of England. *

Yes
No

I have been advised that I am free to terminate any or all sessions at any time. *

Yes
No

I understand that - (1) Payment needs to be made within 24 hours of receipt of appointment confirmation (unless otherwise arranged) (2) Refunds for cancellation can be made up to 24 hours before an appointment. Cancellations after this point will not be refunded. (3)Cancellations made less than 24 hours before an appointment or missed sessions will be billed at full rate *

Yes
No

I have agreed to participate in each session to the best of my ability. *

Yes
No

I have accurately provided background information as requested by the hypnotist/hypnotherapist and confirm that I have no conditions that mean hypnosis in contraindicated. *

Yes
No

I understand that confidentially regarding my sessions will be honoured unless the practitioner feels that I or someone else are in danger, in which case disclosures will be kept to a bare minimum necessary for my protection or the protection of a third party. *

Yes
No

I understand that sessions may be recorded for my own protection and for that of the practitioner. I have been informed that copies of any and all recordings are available to me but will not be made available to any third party without a court order instructing Sudbury Hypnosis to make copies available. *

Yes
No

Signed (Please type legal name)

If you filled this form on behalf of someone else, please type YOUR name followed by your relationship to that person (i.e. parent, carer etc.)