Confidential Client Questionnaire & Agreement

Title

First Name

Last Name

Email

Your Time Zone

Mobile

Alt Number

Occupation

Marital Status

Gender

Age

No. of Children

Are you Left or Right Handed?

Service

Preferred Location

Preferred Consultant

How Did You Hear About Us?

What personal changes do you want?

How much money / time have you invested so far in trying to make this positive change?

Have you personally experienced Hypnosis, NLP or Havening before? (if YES, provide details)

Are you currently undergoing any medical or psychological treatment? (if YES, provide FULL details)

Are you currently taking or taken any medication in last 6 months? (If YES, provide FULL details)

Have you ever been diagnosed with diabetes, sleep apnoea, epilepsy or a heart condition? (If YES, provide FULL details)

Is there anything else that you haven't told us / any other information we need to know? (If YES, please provide details)

Name of local friend or relative

Relationship

Mobile

Home/Work Tel:

What is the testimonial/outcome you would most like to write after our work together?

The information I provide is true and accurate to the best of my knowledge.I understand that Chris and Linzi Meaden maintain a confidential record of the services provided to me.I acknowledge that sessions may be audio or video recorded only when I give my explicit consent, and that any recordings are stored securely and deleted within 7 days in accordance with the Privacy Policy. I also understand that I may withdraw my consent to session recording at any time, and that withdrawing consent does not affect the lawfulness of any recordings made before the withdrawal.I understand that an AI-assisted note-taking or transcription tool may be used during my session to help create accurate notes, but only when I have given consent. I acknowledge that any audio, text, transcript, or temporary data generated through such tools is stored securely and deleted within 7 days, and that I may withdraw this consent at any time.I acknowledge that my personal information will not be shared with anyone else unless I request it, provide consent, or unless disclosure is required by law or necessary to prevent serious harm.I confirm that I have fully read, understood and agree to the full Terms & Conditions and the New Client Information, including the Missing, Cancelling or Rescheduling Appointments Policy.I understand that Hypnosis, NLP, DHE, the Havening Techniques, Coaching, TFT and other modalities used by Chris and/or Linzi Meaden are not medical treatments, but psychological and behavioural techniques designed to support positive personal change.With this understanding, I give permission to Chris and/or Linzi Meaden to guide me through these processes, and I understand that I can pause or stop the session at any time.

Select 'I Agree' Once You've Fully Read The T&Cs And Above

Confidential Client Questionnaire & Agreement

Personal Change

In Case of Emergency

DECLARATION & CONSENT