Client Information Form

Please complete this information form as fully as you can at least 48 hours before your first appointment. Any information supplied is confidential and is not shared with anyone else except in the situations described in the Client Agreement.

Name

Home Phone Number

Mobile Phone Number

Home Address

Date of Birth

Current Age

Occupation

Have you ever been diagnosed with or treated for Epilepsy?

Yes No

Have you ever been diagnosed with or treated for Depression or another mental health condition?

Yes No

Have you ever received counselling, psychological or psychiatric treatment?

Yes No

Do you have any mobility problems (e.g. difficulty climbing stairs or you require wheelchair access)?

Yes No

If you answered yes to any of the above questions, please give details

Name and address of your GP

Any other health or medical information you feel is relevant, including prescribed medications

Name

Phone Number

Email Address

Relationship to You

Please describe the issue(s) that you are seeking therapy for

How long have you experienced the issue(s) and when did it/they first start?

Have you previously tried any other medical or therapeutic approaches for the issue(s) - including Hypnotherapy, Counselling, CBT and/or other talking therapies?

Please describe what you wish to achieve from therapy

Have you ever experienced hypnosis or hypnotherapy before? If so, please describe your experience

Please provide any additional information you feel may be relevant

On a scale of 1 to 10, where 1 is not committed and 10 is 100% committed, how committed are you to overcoming your issue(s)?