Hypnotherapy Consultation and Consent Form

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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: *

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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?

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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

Data Protection & Privacy

We are committed to protecting your privacy. We take special precautions with your sensitive personal data and we will process your data lawfully and as described. We only process the data we need for as long as we need to and we respect all of your rights under GDPR. We will never sell, share or otherwise abuse your data. You can contact us at anytime to request your data, change your preferences or request that your data be deleted. GDPR is the European privacy law designed to protect you and give you control of your data.

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