Information Form

The information gathered here is for the purposes of providing coaching sessions. You will not be added to mailing or marketing lists and all information is strictly confidential.

Name

First Name

Last Name

Date of birth

YYYY

Home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number

Why do we need this? We only use phone numbers as a back up means conducting a hypnotherapy session in the event of technical difficulties.

General practitioner/Doctor

Doctor surgery address

Describe your living situation

Are you married or single? Do you live with others? Do you have any children that you are responsible for?

What is your current occupation?

If none write n/a

Describe the problem that has brought you to hypnotherapy

Questions to think about: How often do you have the problem? How long have you had it? Does it get better/worse? What areas of your life and health does this problem affect?

What help have you had for this problem so far?

Describe any doctors/therapists or specialist help that you have sought for this problem. What was the outcome?

For more information on how we use and store your details see our privacy policy.