Details

Milford Hypnotherapy

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Milford Hypnotherapy
Client Intake Form

* Indicates required field

Name *

First

Last

Contact Number *

Email *

House number and postcode. *

Date of Birth *

Occupation *

How did you hear about me ? *

Internet Search Advertisment Friend Other

Have you had hypnotherapy before ? *

Yes No

If so, what for? *

Generally, how did it go for you? *

Reason you are coming to Milford Hypnotherapy *

List any medication being taken, and reason ? (If none write "none") *

Any medical issues - such as Diabetes, Epilepsy, Heart conditions etc.. *

GP name and address *

Part 2 of 4

List any fears or issues *

List three of your favourite colours *

What is your favourite season ? *

What kind of weather do you like the best ? *

Please list at least three benefits that you would feel by making the change/s that we are working on *

List three of your pastimes or hobbies *

Complete this sentence: I am happiest when… *

Complete this sentence : I am most relaxed when *

Part 3 of 4

Have you ever experienced any of the following. Please tick box. *

Extreme depressed mood Dramatic mood swings Extreme anxiety Panic attacks Phobias Sleep disturbances Hallucinations Unexplained losses of time Unexplained memory lapses Alcohol/substance abuse Frequent body complaints Stomach issues Eating disorder Body image problems Repetitive thoughts (e.g. obsessions)

Have you ever experienced any of the following ? *

Suicidal thoughts Homicidal thoughts None of the above

If yes, when? *

Part 4 of 4

Confidentiality

I adhere to the ethical code of the General Hypnotherapy Standards Council and the GDPR and will maintain your personal data in the strictest confidentiality.
I will not disclose your personal information to any third party unless required to do so by law.
The information you provide during the course of your treatment will be held in strict confidentiality as required by GHR and GDPR.

I am happy to receive updates and information which is consistent with my treatment from Milford Hypnotherapy such as techniques, MP3s etc… *

Yes No

PAIN ONLY - Are you willing to see or have seen a GP ? *

Yes No

Client signature (When you visit sign paper version)

Date

Client Signiture

Submit

QUALIFICATIONS

Diploma in Clinical Hypnotherapy and EFT, Nov 2016 www.innervisions-directory.co.uk/index.htm
Licensed Sanomentolgist and Rapid Pain Eliminator, Jan 2019.
Sanomentology is accredited with the IPHM ( International Practitioners of Holistic Medicine )
Registered with the GHR (General Hypnotherapy Register)
Insurance with Balen insurers.

Home
Anxiety / Depression
Fears and Phobias
P.T.S.D
Pain
Contact
Testimonials
Hayfever
Smoking cessation
Freedom from addiction
GDPR and Client Commitment

Milford Hypnotherapy​Client Intake Form

Part 2 of 4

Part 3 of 4

Part 4 of 4

Confidentiality

QUALIFICATIONS

Milford Hypnotherapy
Client Intake Form