New Client Intake Form

You are completing the following intake forms: Hypnotherapy New Client Intake Form - Strictly Confidential

Profile Information
Questionnaires
Consents

First Name

Last Name

Phone/Mobile

Address

Address Line 1

Address Line 2

Town

County / City

Postcode

Date of Birth (DD/MM/YYYY)

Have you been to see a hypnotherapist before - If YES, how did you find your previous experience(s)?

Have you ever had any other type of therapy / counselling

Issue/s you would like to address in therapy today

Marital Status

Name and number of a person to contact in the event of an emergency

Their relationship to you

Spouses / Partners name:

Do you have children - If yes, how many?

Do you have any fears or phobias - If yes, please describe briefly:

Medical History

Have you ever been diagnosed with a mental disorder or illness - If yes, please give a little more detail:

Have you been under regular medical or psychological treatment in the past year - If yes, please give a little more detail:

Have you had or do you now suffer from any prolonged or acute illness - If yes, please give a little more detail:

Have you ever been treated for an emotional / behavioural problem - If yes, please give a little more detail:

Terms & Conditions

1. I have been advised by Gail Marra (Clinical Hypnotherapist) the scope of hypnotherapy practice and I give my full consent to
receiving hypnotherapy sessions with Gail Marra in todays’ session and in any future sessions.
2. I understand that results vary and that Gail Marra (hereinafter called The Practitioner) is unable to guarantee results.
3. I understand that Hypnotherapy is not a replacement for medical treatment, psychological or psychiatric treatment or counselling. I
also understand The Practitioner does not treat, prescribe for or diagnose medical conditions.
4. I understand that The Practitioner is a facilitator of hypnosis or hypnotherapy and is not practising any other profession that requires a
license under UK Law.
5. I am aware and understand that in some cases it may be necessary for The Practitioner to respectfully touch my shoulders, hands,
wrists, arms, legs, sternum, face or forehead in order to assist me in relaxation. I give The Practitioner permission and consent to do
so in order to help me establish a beneficial state of hypnosis.
6. I have been advised that I am free to terminate any or all sessions at any time I have agreed to participate in each session to the best
of my ability.
7. I have accurately provided background information as requested by The Practitioner.
8. I understand that confidentiality regarding my sessions will be honoured between myself and Gail Marra subject to the NCH code of
ethics and the Data Protection Act 1998.
9. I agree to pay Gail Marra for all services rendered on or before each session unless other arrangements have been agreed in writing.
I understand that all pre-paid sessions must be used within 180 days of todays’ date

I agree to all the terms listed above: – Required

Email Communication

I would like email notifications of new, cancelled, and rescheduled appointments

Signature

Sign Here

Medical History

Terms & Conditions

Accreditations

Harley Street, London

Still Unsure?