Consent Form

Online Consent Form for Hypnotherapy

* Indicates required field

Name *

First

Last

Address *

Line 1

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City

State

Zip Code

Country

Date of Birth (DD/MM/YYYY) *

Phone Number *

Email *

Are you happy to receive occasional emails from us? (Select One) *

Marital Status *

Number of Children *

Hobbies and Interests *

Occupation *

What would you like help with during your Hypnotherapy Sessions? *

Do you have any symptoms associated with the issues you are seeking help for? If so, what are they and how long have you had them? *

Any previous treatment/therapy for this issue? *

Do you have any fears/phobias? If so, what are they? (Eg. Water, Lifts/Confined Spaces, Escalators etc) *

Do you have any compulsive habits? *

Do you suffer from asthma or allergies? (Select One) *

Do you suffer from Diabetes? (Select One) *

Have you suffered from epilepsy in the last two years? (Select One) *

Have you ever suffered from depression/Bi-Polar? (Select One) *

Have you ever had treatment from a Psychologist/Psychiatrist/Therapist? If yes, please provide details: *

Have you ever been hypnotized before? If so, what for? *

Current state of health: *

Are you currently taking any drugs/medication? (Prescribed/over the counter/recreational drugs/herbal remedies): *

Details of any major operations: *

Doctor’s Name and Address: *

Are you happy for us to contact your GP if we feel it is necessary? *

Where did you hear about us? *

By ticking below I give my consent to receiving Hypnotherapy: *

I Give Consent

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