Good Night's Sleep Hypnotherapy Research Consent Form

Good Night's Sleep Hypnotherapy Research Consent Form

Welcome to Good Night’s Sleep Hypnotherapy Research! Thank you for participating in the three weeks online research. Please complete this research consent form. I have created a private Facebook Group called Good Night’s Sleep Hypnotherapy - the link is in the email to join it. It is where we can share learnings and hypnosis audios, ask questions and encourage each other. Having a group helps us to be accountable for achieving the goal of a good night's sleep especially when we are changing our habits. All information is Data Protection (GDPR) and Confidential. I collect personal information to help provide a safe and effective therapy. In handling this information, I am bound by the General Data Protection Regulations (GDPR). All T&Cs on www.whatisyourstoryhypnotherapy.co.uk
Name*

First NameMiddle NameLast NameSuffix
Email
example@example.com
Phone Number

Area CodePhone Number
Date of Birth*

DayMonthYear
1. How long does it take you to fall asleep at night? (Approx.) *
MINUTES
2. How many hours do you sleep for at night? (Approx.) *
Hours

3. Please rate the quality of your sleep?

	1	2	3	4	5	6	7	8	9	10

1 is Poor, 10 is Excellent

4. Do you frequently wake up during the night?*

YesNo
5. Do you know the reason for waking up?
6. Please indicate if any of the following behaviours occur during your sleep (please check all that apply):*

SleepwalkingDry mouthAwakening with heart palpitationsSleep talkingBody jerking/ legs kickingHeartburnNightmares/ dreamingNocturnal coughExcessive sweatingTeeth grindingNone applyOther
7. How many servings of caffeine do you consume on a typical day?*
8. Do you look at your mobile phone/tablet:

at night?when you wake up?both evening and morning?neither evening or morning?
9. Medical History*

AsthmaBipolar DisorderCOPDDepressionDiabetesEpilepsyFibromyalgiaGERD / HeartburnHeart problemsHigh blood pressureSurgery for sleep apnea / UPPPMigraine headacheNonePTSDOther
What’s next
When you complete your Research Consent Form, I’ll send you an email to include:
- Good Night’s Sleep Hypnosis Audio approximately 15 minutes long
- Good Night’s Sleep Checklist for any changes you may want to make
- The research questionnaire link to track your progress. The questionnaire will take approximately 7 minutes to complete. The questionnaire is to be completed 3 times a week.
Here's a video where I go through the Facebook group content, the Good Night's Sleep Tube Map Checklist, and the Good Night Sleep Hypnotherapy Research Questionnaire.
There's a Good Night Sleep Hypnosis where you walk along the beach, recalling your happy memories and events to draw on. During the walk, you come across a beach hut with a perfect bed and experience a Good Night's Sleep. Watch the video below.
https://youtu.be/JAfaY5IPm0c
10. Thank you for completing the pre-questionnaire. Do you consent to take part in the Good Night Sleep Hypnotherapy Research?*

YesNo
Should be Empty: