Consent Form

Name

First Name

Last Name

Email

Home Address

Your home address is required for insurance details only and you will never be contacted this way unless specifically requested by you.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Click on appropriate sentences to highlight relevant statements.You can provide further information below. * [Required last 2 sentences.]

I have received Hypnotherapy before.

I have suffered with Depression.

I have suffered/ been treated for or suspect i have a psychiatric disorder,

I have suffered from Epilepsy and or a Heart Condition. {Provide more details below.}

I am currently taking medication prescribed or otherwise.{ Provide details in box below

I am currently in good health.Please provide details in box below if you do not tick this box.

* I have accurately provided information as requested and confirm that I have no conditions that mean hypnosis should not be undertaken.

* I confirm I have read and understood the IMPORTANT INFORMATION section at the bottom of this form and I consent to receiving Hypnotherapy & NLP [REQUIRED]

Date of Birth

MM

DD

YYYY

Fears or Phobias

How did you hear about us?

Please provide any additional information here, including Medication, Health conditions or any information you may consider to be useful to your therapist.

Please complete and submit this consent form prior to your first Hypnotherapy session with us. This will help us provide the very best treatment plan specifically for you. Thank You

Please use the contact page for new enquiries.

IMPORTANT INFORMATION

PLEASE READ BEFORE SUBMITTING YOUR CONSENT

Before beginning any new therapy program it is recommended that you seek medical advice from your personal physician or mental health practitioner.

Your Therapy course is not intended to be a substitute for the medical advice of a licensed physician or mental health care professional. You should consult with a doctor in any matter relating to your health.

If you suffer from mental illness or suspect you have a psychiatric disorder, please contact a professional mental health physician or doctor before undertaking any course of therapy.

*Please click the last sentence from the list above to confirm you have read and understood this paragraph and you are happy to go ahead with your course of Hypnotherapy & NLP.

Thank you