Consultation Form
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Hypnotherapy Consult Form

Please complete the following form
BEFORE our first Hypnotherapy Session together. 

Any and all information follows strict GDPR guidelines, is protected & stored safely.

Have you been hospitalized in the last 12 months?
Are you suffering from a medical condition, illness, or injury?
Have you undergone an operation or will you be undergoing surgery within the previous/next 2 months? Are you or do you plan to undergo medical tests?
Which Hypnotherpy sevice do you need?



Do you or have you ever suffered from:


Psychosis, Brain Injury, Bipolar Disorder, Seizure Disorder, Obsessive-Compulsive Disorder, Tourette's Syndrome, Epilepsy, Mental disorder, Diagnosed Severe Depression. Alcoholism, Drug addiction. 

Caution Diagnosis - Hypnotherapy can benefit you but with care & personalised support. 


Mild depression, anxiety, current heart conditions, high/low blood pressure, physical injuries/mobility issues...

I do not suffer from any medical problems other than the ones listed on this form. I agree to continue with Hypnosis and I will seek medical approval from my GP should the situation with my health change. I understand that my Hypnotherapist is qualified in the services advertised. I understand that my Hypnotherapist is covered with public liability insurance as well as Therapy Insurance and a member of relevant associated bodies.

Should I become positive with COVID-19 prior to our appointment, I will re-arrange when I can confirm clear and negative results. I understand Sam operates a 48 hour cancellation policy and I will adhere to this to the best of my ability. 

Thanks for submitting!