Hypnotherapy Consultation and Consent Form

Page 1 of 3

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: *

SUBMIT

(disabled)

Page:

1 2 3

Page 2 of 3

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?

SUBMIT

(disabled)

Page:

1 2 3

Page 3 of 3

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: *

Tap or click on the signature above to sign

Appointment Guidance

If you have tested positive for COVID-19, or have any symptoms of COVID-19 (see below) please do not attend your appointment. Please contact us as soon as you know you will be unable to attend so we can reschedule.

COVID-19 Symptoms:

a high temperature or shivering (chills) – a high temperature means you feel hot to touch on your chest or back (you do not need to measure your temperature)
a new, continuous cough – this means coughing a lot for more than an hour, or 3 or more coughing episodes in 24 hours
a loss or change to your sense of smell or taste
shortness of breath
feeling tired or exhausted
an aching body
a headache
a sore throat
a blocked or runny nose
loss of appetite
diarrhoea
feeling sick or being sick

SUBMIT

(disabled)

Page:

1 2 3

Beauty Forms