Part 1

Your Name (required)*

Date Of Birth*

Postal Address* (Include country if outside UK)

Your Email*

Telephone* (include international code if outside UK)

Skype ID*

Marital Status

No of Children

Hobbies & Interests

Occupation

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)

Other Fears/Phobias

Compulsive Habits

Do you suffer from asthma or 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 provide details)

Have you had hypnosis before? (If yes please provide details)

Where did you hear of Sudbury Hypnosis?

Current state of health

Are you currently taking any drugs/medication

Details of any major operations

Part 2

Part 2 consists mainly of statements about what you can and cannot expect from our work together. If you understand and agree with the statement, check the 'yes' box. Please give details of any that are marked 'no' at the end and we will contact you to discuss it further before our session.

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

yesno - I understand that results vary and that the practitioner may not guarantee results

yesno - I understand that Hypnosis/Hypnotherapy is not a replacement for medical treatment, psychological or psychiatric services or counselling

yesno - I understand that the Hypnotist/Hypnotherapist does not treat, prescribe for or diagnose any condition.

yesno - 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.

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

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

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

yesno - 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.

yesno - 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.

yesno - I understand that payment must be made in full before any session can commence.

Additional Info