Intake Form

Buttons Bunny with Sian Collins CI.Hyp CCPD MPMH DHP CAHCMH Confidence Coaching STRICTLY CONFIDENTIAL © Sian Collins 2024

Ages 5 to 7
Childs Name*
Age*
Parents Name 1*
Parents Name 2
Email*
Phone Number *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medication currently being taken*
Last date of visit to the doctors
You can complete this part with your child or they can complete independently.
Anxiety - The bubbles or the tight feeling in your belly or chest?*

Not at allSometimesOftenAll of the time
Confidence - How confident do you feel when you go outside, to school or to play?*

Not at allSometimesOftenAll of the time
Confidence - How confident do you feel at school?*

Not at allSometimesOftenAll of the time
Confidence - How confident do you feel at home?*

Not at allSometimesOftenAll of the time
Stress - How much are you worrying about getting things right and what others think of you?*

Not at allSometimesOftenAll of the time
Sleep - How well are you sleeping and is it easy for you to go to sleep?*

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:-
Type a question

ConfidenceEating good foodsSleep BetterStop worrying what others think
Type a question

FootballTest/Exam successConcentrationNetball
Type a question

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 personalized 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 Sian Collins at sian@siancollins.co
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.

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Date*

DayMonthYear
Date

My Products*

Buttons Bunny Adventure by Sian Collins - Personalised Recording for your Child Product Image

Buttons Bunny Adventure by Sian Collins - Personalised Recording for your ChildA bespoke recording of Buttons Bunny's first adventure with your child is included in the story at the end. Buttons Bunny is a funny lovable character and through his many adventures helps your child create natural confidence and positive beliefs about themselves. If you want your child to thrive in life, have high self-esteem, and ultimately BE HAPPY Buttons adventure stories will teach your children how important it is to tell yourself positive words. The underlying theme running through each of the stories are; ‘You are Strong, Kind, and Brave, you are more than enough. There is nothing you cannot achieve once you put your mind to it and tell yourself the right words’.

£33.00

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Buttons Bunny with Sian Collins CI.Hyp CCPD MPMH DHP CAHCMH Confidence Coaching STRICTLY CONFIDENTIAL © Sian Collins 2024

You can complete this part with your child or they can complete independently.

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

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