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ALCOHOL
SMOKING CESSATION
Hypnotherapy and The Mind
Home
WEIGHT LOSS
One to One Coaching
Journalling for Weight Loss
TESTIMONIALS
Submit Testimonial
Blog
Contact
Consent Form
ALCOHOL
SMOKING CESSATION
Hypnotherapy and The Mind
Online Consent Form for Hypnotherapy
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Are you happy to receive occasional emails from us? (Select One)
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Occupation
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What would you like help with during your Hypnotherapy Sessions?
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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?
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Any previous treatment/therapy for this issue?
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Do you have any fears/phobias? If so, what are they? (Eg. Water, Lifts/Confined Spaces, Escalators etc)
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Do you have any compulsive habits?
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Do you suffer from asthma or allergies? (Select One)
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Do you suffer from Diabetes? (Select One)
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YES - TYPE 1
YES - TYPE 2
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Have you suffered from epilepsy in the last two years? (Select One)
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Have you ever suffered from depression/Bi-Polar? (Select One)
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YES - DEPRESSION
YES - BIPOLAR
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Have you ever had treatment from a Psychologist/Psychiatrist/Therapist? If yes, please provide details:
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Have you ever been hypnotized before? If so, what for?
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Current state of health:
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Are you currently taking any drugs/medication? (Prescribed/over the counter/recreational drugs/herbal remedies):
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Details of any major operations:
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Doctor’s Name and Address:
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Are you happy for us to contact your GP if we feel it is necessary?
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