Intake Form - Confident Woman Mastery - 1:1 Coaching & Hypnotherapy with Sian Collins Online

Name*

Email Address*

Phone Number*

Emergency Contact Name*

Emergency Phone Number*

Your Age*

Occupation*

Address*

Number | Name property

Street Address

Postal / Zip CodeCountry

When was your last visit to the doctors & are you currently taking medication?

How calm are you daily?

How secure do you feel in yourself?

How easily does your creative mind flow?

How restful is your sleep?

How confident are you personally?

How confident are you professionally?

How much do you value yourself?

How happy do you feel right now?

Relationships - How fulfilling are your relationships?

Relationship with your mother – How positive is your relationship with your mother?

Which area do you most want to work on? *

What's the one thing you most want help with right now?*

How is this issue holding you back?(Describe as fully as you can—your thoughts, feelings, and how it affects your life. The more detail, the more I can support you.)*

Imagine this issue is gone—how would your life be different?(Share your full vision. The more detail, the better I can support you.)

Terms & Conditions – Hypnotherapy & Coaching

Eligibility

Hypnotherapy is not suitable for individuals diagnosed with epilepsy or psychotic illnesses.

By participating, you confirm that you are responsible for ensuring it is safe and suitable for you.

Mental Health & Safety

Sian Collins provides hypnotherapy, mindset coaching, and wellbeing support. This work is not a substitute for medical, psychiatric, or emergency care.

This service is not suitable for individuals who are currently experiencing suicidal thoughts, self-harm behaviours, or are in a mental health crisis.

By engaging in this work, you confirm that you are not currently in crisis and understand that additional or alternative professional support may be required.

Medical Disclaimer

Sessions are not a substitute for medical care. You should consult your GP or healthcare professional before changing any medications.

Confidentiality

All sessions and personal information are kept strictly confidential, except where disclosure is required by law or safeguarding concerns arise.

Commitment & Results

Your results depend on your engagement, commitment, and consistent use of any recordings or exercises provided.

Outcomes vary by individual, and results are not guaranteed.

Non-Refundable Policy

Sessions are non-refundable once the first session begins.

Email responses

Monday– Wednesday 10 am–4 pm.
Appointments: Monday & Wednesday, 10 am–4 pm, or by prior arrangement.

Client Declaration

By booking and attending sessions, I confirm that:

1. I have read and understood these Terms & Conditions.
2. I am not currently experiencing suicidal thoughts, self-harm behaviours, or a mental health crisis.
3. I understand that this service is not a substitute for medical, psychiatric, or emergency care, and additional professional support may be required.

Please type in your name below to confirm you have read the Terms & Conditions above and to give full consent for Sian Collins to use hypnotherapy, coaching and associated techniques with you.*

Date*

DayMonthYear

Intake Form | Free To Be You - with Sian Collins

Rate each area from 0 = struggle | 10 = thriving