First Name *
Surname *
Age *
Date of Birth *
Marital Status *
Address *
Postcode *
Mobile *
Home Telephone
E-Mail Address *
Occupation/Employer
Name, address & phone number of your primary Health Care Provider (Doctor) *
Date of last visit
List all medications including OTC medications *
Have you ever been diagnosed as Schizophrenic? YesNo
Have you ever been diagnosed with Epilepsy? YesNo
If yes, you must obtain a letter of clearance from your Doctor before undergoing any form of hypnosis Letter attached
From the list below tick the issue/s that concern you
Addictions
Smoking
Drinking
Drugs
Gambling
Food
Other
Achieving Goals
Anxiety
Anorexia
Bulimia
Bedwetting
Career
Childhood Problems
Concentration
Confidence
Compulsive behaviour
Depression
Exams (inc preparation)
Eating Problems
Fears
Guilt
Motivation
Memory
Nail Biting
Nerves / Nervousness
Pain Control
Panic Attacks
Phobias
Public Speaking
Fertility
Relationships
Relaxation
Stress
Self-Esteem
Self Hypnosis
Sexual Problems
Speed Reading
Skin Ailments
Weight Problems
Other:
I have read and understood all the information provided to me prior to my session. YesNo
I’ve disclosed all necessary information, honestly and to the best of my knowledge. YesNo
Signed
Date
