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.
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.