Adult Therapy & Wellbeing Client Form - A Gentle Pace Therapy | Newcastle

  • A Gentle Pace – Adult Therapy & Wellbeing Client Form

    To be completed prior to initial consultation

  • The information provided helps sessions remain safe, supportive and appropriately tailored to your needs. Some therapeutic approaches, including guided relaxation and hypnotherapy, may not be suitable for certain medical or psychological conditions, so please answer as openly and accurately as possible.

    All information is treated confidentially and stored securely in line with GDPR regulations.

     

  • Personal Details

  • Date of Birth*
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  • Therapy & Support Focus

  • Please select the area that best reflects your current goals:*
  • Are you currently receiving support from any healthcare or mental health professionals? Examples may include: - GP - Counsellor - Psychiatrist - Mental Health Team - Specialist Practitioner Please provide brief details if relevant
  • Are there any current risks or safeguarding concerns that it would be important for me to be aware of? Examples may include:- thoughts of self-harm- suicidal thoughts- current crisis support involvement- risk from others- significant instability or distress.

  • Medical Details

  • Some therapeutic approaches used within sessions, including guided relaxation and hypnotherapy, may not be suitable for certain medical or psychological conditions or alongside some medications.

    The following information helps ensure that support is safe, appropriate and tailored to your individual needs. Please answer as openly and accurately as possible.

    If additional information is needed, this can be discussed further during your consultation.

  • Mental Health Conditions*
  • Neurological Conditions*
  • Cardiovascular Conditions*
  • Respiratory Conditions*
  • Chronic Pain Conditions*
  • Substance Use Conditions*
  • Disasociative Disorder Conditions*

  • Medications

  • Psychiatric Medications*
  • Neurological Medications*
  • Cardiovascular & Blood Pressure Medications*
  • Pain Medications*
  • Respiratory Medications*
  • Sleep & Sedative Medications*
  • Substance Use Treatment Medications*

  • For purposes of safeguarding your health and wellbeing please provide the contact details of your GP. By giving these details you authorise us to contact your GP should a situation or disclosure arise that we feel places, or has the capacity to place, you or others at risk of harm.

  • Date*
     - -

  • In line with GDPR regulations all data will be stored securely and never shared with third parties.

     

    A Gentle Pace Hypnotherapy is part of Family Mental Fitness North East

     

    • Please read this information about medical conditions and medications. 

    • Medical Conditions

      Mental Health Conditions

      Schizophrenia & Psychosis – Hypnosis can blur reality and potentially trigger or worsen symptoms.

      Bipolar Disorder – Hypnosis could induce manic or depressive episodes.

      Severe Depression – Hypnotherapy might be useful in some cases but could also bring up distressing emotions.

      Severe Anxiety & PTSD – While hypnosis can help, it may also cause re-experiencing of trauma if not handled properly.

      Neurological Conditions

      Epilepsy – Hypnosis can sometimes trigger seizures in susceptible individuals.

      Dementia & Cognitive Impairments – Hypnosis requires a level of concentration and memory that might be compromised.

      Cardiovascular Conditions

      Heart Disease & Hypertension – The deep relaxation of hypnosis may cause fluctuations in blood pressure, which could be risky for some patients.

      Respiratory Conditions

      Asthma – Emotional triggers during hypnosis could provoke an attack in sensitive individuals.

      Chronic Pain Conditions

      While hypnosis can help with pain management, an underlying medical diagnosis should be confirmed first.

      Substance Use Disorders

      Hypnosis may be helpful in addiction treatment but requires careful consideration of withdrawal symptoms.

      Dissociative Disorders

      Hypnosis could increase dissociation or confusion in individuals with conditions like Dissociative Identity Disorder (DID).

       

      Medications

      Psychiatric Medications

      Antidepressants (SSRIs, SNRIs, MAOIs, TCAs) – May alter mood and cognitive function, affecting suggestibility.

      Antipsychotics – Used for schizophrenia, bipolar disorder, or severe depression; can cause sedation or dissociation.

      Anxiolytics (e.g. Benzodiazepines, Buspirone) – May reduce anxiety but can also impair memory and focus.

      Mood Stabilizers (e.g. Lithium, Valproate, Lamotrigine) – Can affect emotional regulation and concentration.

      Neurological Medications

      Anti-Epileptics (e.g. Carbamazepine, Phenytoin, Gabapentin) – May impact cognitive function and response to hypnosis.

      Dementia Medications (e.g., Donepezil, Memantine) – Can influence memory and awareness levels.

      Cardiovascular & Blood Pressure Medications

      Beta-Blockers (e.g. Propranolol, Atenolol) – Can blunt emotional responses and reduce anxiety, potentially affecting hypnotic depth.

      Antihypertensives (e.g. ACE Inhibitors, Calcium Channel Blockers) – Can cause dizziness or fatigue, influencing a client’s comfort.

      Pain Medications

      Opioids (e.g. Morphine, Codeine, Oxycodone) – May cause drowsiness, impaired cognitive function, or altered pain perception.

      NSAIDs & Paracetamol – Generally safe, but chronic pain conditions should be medically assessed first.

      Respiratory Medications

      Asthma Inhalers (e.g. Salbutamol, Steroids) – Stress or emotional triggers during hypnosis could exacerbate symptoms.

      Sleep & Sedative Medications

      Sleeping Pills (e.g. Zolpidem, Zopiclone, Melatonin) – Can cause drowsiness, confusion, or altered states of consciousness.

      Substance Use Treatment Medications

      Methadone & Buprenorphine – Used for opioid addiction; can affect mental clarity and emotional regulation.

      Naltrexone & Disulfiram – Used for alcohol dependence; can cause anxiety or physical side effects.

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