Intake Form

First name*

Last name*

Preferred Name

Email*

Telephone Number*

Birthday*

Day

Month

Year

Address*

Emergency Contact Name*

Their relationship to you*

Emergency Contact Telephone Number*

Occupation

Doctors Name & Address*

Current Medication being taken*

Current and Past Medical History*

Please check any areas of concern

Addictions

Drinking, Smoking or Drug use

Compulsive behaviours

Anxiety / Stress / Panic Attacks

Guilt / Shame

Fears / Phobias

Eating / Diet / Weight / Eating disorders

Depression

Confidence / Self Esteem

Self Sabotage / Imposter Syndrome

Motivation / Procrastination / Achieving Goals

Career / Business / Money

Pain Management / Physical Issues

Relationship issues

Sleep

Other

I Confirm that I have no history of psychosis, personality disorder, epilepsy or any other medical reason why I can't engage in Hypnosis / Hypnotherapy or RTT

Please read the Terms & Conditions before completing this form. Click here to view/download

Signature - I Confirm that I have read and agree to the terms and conditions*

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GHR General Hypnotherapy Register Registered Practitioner

WhatsApp: 07534513041

Email: maddiekleinhofs@gmail.com

Address: Unit 1, The Old Rowing Club, 20 Caskgate Street, Gainsborough, DN21 2DL

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