Hypnotherapy Consultation and Consent Form

Client Details

Name: *

Date of Birth: *

Contact Number: *

Email: *

Occupation: *

Emergency Contact

Emergency Contact Name: *

Emergency Contact Phone: *

Relationship to you: *

Medical History

Are you currently taking any medication or supplements? *

Please list: *

Do you have any allergies? *

Please list: *

Do you have any medical conditions? *

Please list: *

Have you recently been unwell? *

Which of the following were you unwell with? *

Please provide more detail: *

Hypnotherapy

Please tell us why you are seeking hypnotherapy right now?

Have you previously received hypnotherapy?

What are your thoughts on your previous experience(s) of hypnosis/hypnotherapy?

Have you ever needed to work with mental health professionals?

Please give details:

Please list any fears, phobias or compulsive tendencies:

How would you like hypnotherapy to help you?

Do you have any other notes you wish to make?

Consent

I hereby authorise the hypnotherapist named below to use hypnosis techniques on me for the purposes outlined in this form, and for future purposes that I may request.

I understand that hypnosis and regression therapy are not medical procedures and that no medical benefits are being offered to me.

I understand that the success of hypnosis and regression therapy depends on my ability to relax, and my desire to create change in myself.

I understand that, because the results of the sessions depend on my own serious participation, the hypnotherapist cannot offer any guarantee of the success of my treatment. I am aware however, that they will do everything reasonable in their ability to ensure my success.

Hypnotherapist Name: *

Client Signature: *

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