2 - Intake Form - MindTime with Sian Collins - 1:1 Women Without Payment Link

Sian Collins - Intake Form

CI.Hyp CCPD MPMH DHP CAHCMH Therapy & Mindset Coaching STRICTLY CONFIDENTIAL © Sian Collins 2025
Name*

First NameLast Name
Email*
Phone Number*
Emergency Contact Name*
Phone Number*
Age*
Occupation*
Address*

Number / Name property

Street Address

CityState / Province

Postal / Zip Code
When was your last visit to the doctors & are you currently taking medication?*
On a number scale of 0 - 10 (0 being a low effect on your life, 10 being very high negative effect) how would you rate the following:- Stress*
Anxiety*
Confidence*
Self Esteem*
Creativity*
Sleep*
Click below on each area's that concerns you most:-*

AnxietyStressSleep problemsDepressionLow Self EsteemSocial PhobiaExcessive WorryOverwhelmDifficulty RelaxingPanic AttacksExam SuccessPublic SpeakingFear / PhobiaMobile Phone AddictionWeight ProblemsEating ProblemsAddictionsSelf HarmIntrusive ThoughtsWorry About Past EventsFear of the FutureConcentrationMotivationProcrastinationPhobia of SickConfidenceSkin ProblemsNervesSuicidal ThoughtsWorrying About Getting Things WrongParental Emotional Wounds from PastWorrying What Others Think of YouDifficulty Making DecisionsTrust IssuesNot Able to Say No to OthersOther
1) Please would you tell me below how your issue effect's your life in a negative way? I.e. how it is stopping your living the life you want *
2) If you did not have this issue, how different would your life be in a positive way? how different would your life look to others? How different would you feel about your life? Please give as much details as possible here*
3) How would you like your life to look if you had no restrictions? really think, if there was nothing holding you back or stopping you achieve your goals i.e. time, money, circumstances etc what would you REALLY want to achieve in your life? How do you want to FEEL about your life?*
Terms & Conditions - Hypnotherapy & Coaching Online with Sian Collins

It is important that you read all the following terms and conditions before proceeding with hypnotherapy and coaching sessions. By engaging in these services, you agree to abide by the following:

Eligibility and Responsibility:

Hypnotherapy is not suitable for individuals diagnosed with epilepsy or psychotic illnesses. By participating in hypnosis or any related therapies, you acknowledge and assume all responsibility for your eligibility and suitability.

Sian Collins shall not be held liable for any consequences arising from the use or inability to use hypnosis, advanced hypnosis techniques, hypnotherapy, or any other therapies.

The information, techniques, methods, and recommendations provided by Sian Collins are not intended to replace the diagnosis and care of a qualified physician or general practitioner (GP). They are also not meant to encourage treatment by individuals lacking recognized qualifications.

If you are using hypnosis and are under medical care for any condition, you must not make any adjustments to your prescribed medication without your doctor's approval. In case of doubt, consult your GP for advice.

All client data is kept strictly confidential.

Consultation and Treatment:

Sian Collins employs rapid transformational therapy and clinical hypnotherapy, which may involve regression to childhood events to identify the root causes of limiting beliefs.

Once the root cause is identified, a process will be undertaken to transform the belief into a positive one.

Clients will receive a personalized recording to listen to for a 33-day period, as it generally takes 33 days to change old unwanted habits. It is crucial for the client to listen to this recording consistently to achieve the desired positive outcome.

Office Hours and Contact:

Email Replies: Monday to Thursday – 10 am to 6 pm

Email: sian@siancollins.co.uk

Appointment Sessions: Monday & Wednesday 10 am to 6 pm

Appointments are available outside of these times by prior arrangement.

Session Format:

Sessions are conducted exclusively online, virtually via ZOOM or GOOGLE MEETS.

Cancellation and Rescheduling:

If you need to cancel or reschedule a session, kindly provide at least 48 hours' notice before the scheduled Session start time, within Monday to Wednesday 10 am to 6 pm. If you fail to cancel your Session within this time frame then you shall forfeit the right to that Session. No refund will be provided. We understand that unexpected circumstances may arise, and we strive to accommodate reasonable requests.

Results and Client Responsibility:

Hypnosis alone does not guarantee success. The client must genuinely desire change, be open to it, and demonstrate motivation during the hypnosis sessions. The client is responsible for listening to their personalized recording and committing to the process of change.

Indemnity and Disclaimer:

Since the information provided is general in nature, individual circumstances may require a different approach. Sian Collins assumes no responsibility for any loss, damage, or expenses incurred as a result of using this information. By agreeing to these terms and conditions, you indemnify and hold Sian Collins harmless against any claims or liabilities arising from your engagement in hypnotherapy and coaching sessions.

Please be aware that these terms and conditions are subject to change without prior notice. It is your responsibility to review them periodically.

By proceeding with our services at MindTime with Sian Collins, you acknowledge that you have read, understood, and agreed to these terms and conditions.
Please type in your name below to confirm you have read the Terms & Conditions above and to give full permission for Sian Collins to use hypnotherapy with you (if applicable your child)*
Date*

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My Products*

MindTime with Sian Collins - Women Entrepreneur 6 Week Elevation Program Product Image

MindTime with Sian Collins - Women Entrepreneur 6 Week Elevation ProgramMindTime's 6-Week Program for Women Entrepreneurs – a transformative journey spanning six, one-hour sessions that will empower you to unleash your full entrepreneurial potential. Our program begins with a one-hour strategy call, delving into your thoughts, helping you gain clarity, and honing your vision for success. You'll chart a clear path forward, setting the stage for your entrepreneurial aspirations. Next, our Power Healing Session, another one-hour gem, will help you unearth and heal any mental blocks that may be holding you back. As you heal and evolve, you'll step into the powerful entrepreneur you were destined to become. The Business Strategy Plan, another one-hour session, will fine-tune your business approach, identifying what's working and what isn't. We'll tailor strategies to fit your unique journey, propelling your business toward new heights. Throughout the program, enjoy four hours of personalized coaching, dedicated to elevating both your personal and business life. These sessions provide tailored guidance and support to help you succeed. But that's not all – you'll receive two bespoke audio recordings and access to our Women Entrepreneur library, ensuring that your journey toward success doesn't end when the program concludes. We are looking forward to having you on this remarkable six-week journey and unlock the entrepreneur within you!

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Sian Collins - Intake Form

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