5. Intake Form - Buttons Bunny with Sian Collins - £69 Bespoke Audio Children 5 to 7

Buttons Bunny with Sian Collins CI.Hyp CCPD MPMH DHP CAHCMH Confidence Coaching STRICTLY CONFIDENTIAL © Sian Collins 2025

Ages 5 to 7
Childs Name*
Age*
Parents Name 1*
Parents Name 2
Email*
Phone Number *
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medication currently being taken*
Last date of visit to the doctors
Please complete this part with your child around how they feel on each area. Please encourage your child to decide their own answers if possible
Not at allSometimesOftenAll of the time
Not at allSometimesOftenAll of the time
Not at allSometimesOftenAll of the time
Not at allSometimesOftenAll of the time
Not at allSometimesOftenAll of the time
It is super easy for me to go to sleep every nightI sometimes find it difficultI sometimes wake upIt is very difficult for me to go to sleep every night
Click below on the areas you would most like to improve:-
ConfidenceEating good foodsSleep BetterStop worrying what others think
FootballTest/Exam successConcentrationNetball
BoxingDancingReadingTimes Tables
How would you like to feel when you wake up in the morning?*
How would you like to feel at school?*
How would you like to feel when meeting new people?*
What's your favourite colour?*
What's your favourite song?*
What's your favourite action figure or film character i.e. frozen, Iron man etc*
Terms and Conditions for "Buttons Bunny" Personalised Audio Recordings

Introduction

Thank you for choosing "Buttons Bunny," a personalised audio recording designed for children ages 5 to 7. These recordings help your child build resilience, confidence, and a strong, positive self-image. Please read the following terms and conditions before using the product.

Disclaimer

The "Buttons Bunny" recordings are not a substitute for professional medical or psychological advice. Always consult a healthcare provider with any questions regarding a medical condition.

The recordings are intended to complement your child's well-being and are not meant to replace professional care.

Limitation of Liability:

Sian Collins is not liable for any special or consequential damages from the use of "Buttons Bunny" recordings. Sian Collins is not responsible for any loss, damage, or expenses from using this information.

Confidentiality:

All client data is kept strictly confidential and will not be shared without consent.

Parental Responsibility & Supervision:

Parents or guardians must supervise the use of the "Buttons Bunny" recordings and ensure a safe, comfortable environment for their child.

Medical Care:

Do not adjust any prescribed medication for your child without consulting a healthcare provider.

Always consult a healthcare provider before starting any new treatment or therapy for your child.

Usage Guidelines Personalisation:

Provide accurate and complete information to ensure the effectiveness of the personalised recordings.

Listening Routine:

For best results, follow the recommended listening routine provided at the time of purchase.

Agreement

By using the "Buttons Bunny" recordings, you agree to these terms and conditions and indemnify Sian Collins from any claims arising from the use of the recordings.

Contact Information:

For questions, please contact us : buttonsbunnybedtimeadventures@gmail.com
Signature - This signature is to confirm your have read the terms & conditional and give Sian Collins full permission to use hypnotherapy with your child noted at the top of this intake form.
Date*

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Buttons Bunny Adventure by Sian Collins - Personalised Recording for your Child
Give your V.I.L.PC (Very Important Little Person) a magical 30-minute 1:1 online session with Sian Collins via Google Meet, where we’ll boost their confidence, spark their imagination, and co-create a personalised adventure featuring the lovable Buttons Bunny—tailored to the areas they need encouragement most. Within 48 hours, you’ll receive a personalised recording of Buttons Bunny’s First Adventure, with your child included in the story! These heart warming tales help children develop natural confidence, self-belief, and happiness, with a powerful message: You are Strong, Kind, and Brave—more than enough, and capable of anything you set your mind to! 🌟🐰

£80.00

Total

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Buttons Bunny with Sian Collins CI.Hyp CCPD MPMH DHP CAHCMH Confidence Coaching STRICTLY CONFIDENTIAL © Sian Collins 2025

Please complete this part with your child around how they feel on each area. Please encourage your child to decide their own answers if possible

Click below on the areas you would most like to improve:-