What Is Your Story Hypnotherapy

Salutation*

Name*

First NameLast Name

Email*

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Job Role/Industry*

Address*

Street Address

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Phone Number*

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Can I call you and leave a message?*

Emergency Contact Full Name*

Emergency Contact Number*

Emergency Contact Relationship to you (partner, mother, father, friend, etc.)*

GP's Name/Name of the Practice Surgery*

GP's Address*

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1. Have you been hypnotised before?

If yes, please give details including approx. dates, why you didn't continue with that hypnotherapist etc.

2. Have you been treated for poor mental health? (Description of poor mental health is on MIND) https://www.mind.org.uk/information-support/types-of-mental-health-problems/mental-health-problems-introduction/about-mental-health-problems/*

Yes or No

If yes, please give any details about poor mental health including approx. dates, etc.

3. Have you been treated for any of these conditions? (tick all that apply)

If you answered yes to any of the above, please can you give more information below:

4. Describe the change you’d like to make using hypnotherapy?

5. How will you know when you’ve achieved it?

6. How does this problem make you feel emotionally?

7. What does it make you feel physically – for example, sensations, tension, pain, relief, heightened senses?

8. How do you currently picture or see yourself in relation to this issue?

9. What are your main ‘can't, must, ought and should’ beliefs? Please give examples of any use of critical words, sayings that puts pressure on yourself/others by setting up unrealistic expectations on yourself or others? For example, "I have to work hard before I can have any fun." "I must do x y and z before I can leave the house", "I can't do that as I tried years a go or someone told me I wasn't any good at that." etc.

10. Do you live with other people? Please say who and their relationship to you.

11. How is the problem affecting your health and sleep?

12. Is there any other relevant information that hasn’t been covered above?

Please read through the terms and conditions and note the following information:

1. I have been advised by Charlotte Phillips the scope of the therapies they provide, and I give my full consent to receiving hypnotherapy sessions from Charlotte Phillips. I understand that results vary from person to person, and the agreement by Charlotte Phillips to work on the issues or problems presented by me, using whatever model or models are appropriate to my situation, in no way implies or guarantees a ‘cure’ of the said issues or problems.

2. It has been explained to me by Charlotte Phillips and I understand that hypnotherapy is a collaborative process, and the degree of progress is dependent on my active participation and engagement in the process. I understand that there are no guarantees offered and that success depends on my active participation and motivation. I understand that I am paying for Charlotte Phillips' time (case studies are free) and not for a guarantee of success.

3. I understand that Hypnotherapy, or any other therapy provided by Charlotte Phillips is not a replacement for medical treatment, psychological or psychiatric services or the appropriate counselling. I also understand that Charlotte Phillips does not treat, prescribe for, or diagnose any medical or mental health condition.

4. I declare that, if advised prior to any session with Charlotte Phillips to seek medical approval, I have consulted with my General Practitioner and/or Hospital Consultant and gained the appropriate medical approval for working with Charlotte Phillips.

5. The number of sessions is discussed and agreed at the start, and I agree to pay for any session prior to it taking place.

6. I understand and agree that my therapy sessions will take place in Charlotte Phillips’ therapy room or online unless by prior arrangement and in exceptional circumstances, only elsewhere.

7. I have been advised that I am free to terminate any or all sessions at any time. I have agreed to participate in each session to the best of my ability, and that contact between sessions will be strictly limited to telephone, email or letter.

8. I have accurately and truthfully answered the questions on this form and provided background information as requested by Charlotte Phillips.

9. I understand that any mp3 download/CD is provided for me at Charlotte Phillips’ discretion. I agree that any such mp3 download or CD is for my personal use only and that it is not to be lent, copied, or sold under any circumstances.

10. Confidentiality is paramount and will be maintained in all but the most exceptional circumstances. I agree that these can include legal action (criminal or civil court cases where a court order is made demanding disclosure, including coroners’ courts); child abuse; if I am an imminent danger to myself or others; and where there is good cause to believe that not to disclose would cause danger of serious harm to others. Most standards of confidentiality applied in professional contexts are based on the Common Law concept of confidentiality where the duty to keep confidence is measured against the concept of ‘greater good’. The sharing of anonymous case histories with supervisors and peer-support groups is not a breach of professional confidentiality. The sharing of open case histories with supervisors and any referring NHS medical practitioner is also not a breach.

Please read:

I, Charlotte Phillips' as a Clinical Hypnotherapist have a duty to respect the confidential nature of the information you share with me. However, there are some limits to this. For example, if I am worried about your immediate safety, that of someone around you or that of a child, I may need to share information and seek advice. We will of course discuss this openly and I will inform you of any actions I feel I need to take.

We need to record our meetings and discussions in documents and electronic records and these may be accessible (where relevant) to fellow professionals and those directly involved in your care. It is important that we discuss any queries or concerns you have about this.

The Mental Capacity Act makes it clear that a person must be assumed to have capacity unless it is established that they lack capacity, and that a person is not to be treated as unable to make a decision merely because they make a decision that others consider unwise. However, if a person is at imminent risk of suicide there may well be sufficient doubts about their mental capacity at that time.

In these circumstances, a professional judgement will need to be made, based on an understanding of the person and what would be in their best interest, in accordance with section 4 of the Mental Capacity Act 2005. The practitioner should take into account the person’s previously expressed and current wishes and views in relation to sharing information with their family and/or friends, and, where practicable and appropriate, consult with colleagues.

I agree to the terms stated above. Signature*

Client's signature agreeing to the terms above.

Date of Signature*

Date

Consent of Parent/Guardian if under 16 years old

First NameLast Name