Please complete the following form prior to your initial appointment.

    • General Information
    • Medical Information
    • Lifestyle Information
    • Presenting Issue
    • Hypnotherapy
    • Consent

    Consent to leave message/text

    Are you currently under the care of a psychiatrist, psychologist or counsellor?

    Do you consider you eat a healthy diet?

    Do you smoke?
    YesNoTrying to Quit

    Any recreational drug use?

    Are you currently having or have had in the past any medical or psychological treatment for this issue?

    Have you ever had hypnotherapy before?


    By submitting this form I confirm that I am willing to be guided through hypnosis for the purposes of self-improvement. I understand that the hypnotherapy I am receiving is not a substitute for normal medical care. I should continue any present medical treatment and consult my regular medical doctor for treatment of new or existing illness. I accept that no guarantee of a cure can be given for any presenting issue or any issues that become apparent during the course of therapy.

    I also agree to the following TERMS AND CONDITIONS:

    If you are running late for an appointment please contact me as soon as possible. Unfortunately a full session cannot be guaranteed if you are late but I will try to accommodate you if possible. Failure to attend an appointment without notification will result in full payment of the session being due. Where the session has been prepaid there will be no refund.

    If it is necessary for you to cancel or reschedule and appointment please give 24 hours’ notice so that the appointment can be offered to another client. If you give less that 24 hours' notice the full fee for that session will be charged.

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