Debbie Waller Client Information Form

Simone Polden, 14 Ivychurch Gardens, Cliftonville, CT9 3YG. Tel: +44 7813 282322 Email:simone@youandmehypnotherapy.co.uk
CLIENT INTAKE FORM
Please read the Terms and Conditions carefully before submitting this form as it contains important information about my services and GDPR
ABOUT YOU
Full name*
Preferred name (what you would like me to call you)*
Date of birth:*

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Address including postcode*
Email*
Phone number*
Is it OK to leave a message on that number?*

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Name and phone number of someone I could contact in an emergency*
Which medical practice are you registered with (name of practice and town)?*
How did you find out about my services?

YOUR THERAPY

This part is about what you want me to help you with. You only need to be brief as we will talk about this in more detail during the consultation.
What issue would you like help with and how is it currently affecting your life? If there is more than one, you can include them here but please indicate which one you would like to address first *
If there is any other information you'd like to give that didn't fit on the form, please put it here
I have read the Terms and Conditions and confirm the following:*

I understand that results will vary and the resolution of any presenting problems or issues cannot be guaranteed.I understand that any information, advice or therapy provided by Simone Polden is not a substitute for medical, psychological or psychiatric treatment and that if I have any doubts or concerns about my health, I will seek advice from an appropriate qualified healthcare professional.I understand and agree to how my data will be used and stored and the conditions relating to confidentiality.I understand that I am free to terminate any or all sessions at any time.I understand that commitment and a positive attitude towards therapy is crucial and that for best results I need to participate to the best of my ability both during and between sessions and listen to the transformational recording daily for at least 21 days following my RTT session.I have accurately and truthfully answered these questions to the best of my ability.
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Today's date:*

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CLIENT INTAKE FORM