Hypnotherapy Client Information Form

Hypnotherapy Client Information Form

Provide your details to get started with hypnotherapy.
Full Name

First NameLast Name
Email Address
example@example.com
Phone Number

Area CodePhone Number
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
What is your main reason for seeking hypnotherapy?
Do you have any of the following medical or mental health conditions? (Select all that apply)

Other
If no options given, please state
How did you hear about our hypnotherapy services?
Please arrive on time. Although we endeavour to be punctual, sometimes sessions may run a little late due to the personal and sometimes emotional nature of the work, so please be patient and understanding if this is the case. If having your appointment online, I will message you as soon as I have completed the previous session.

I agree to allow my Hypnotherapist to hypnotise me. I will do my very best to follow ALL instructions so I can benefit from this very effective therapy.
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