For all new patients: Please complete this form before first appointment. Thank you.



    Consent to leave message/SMS: YesNo

    Street Address:




    Date of Birth:


    Gender: MaleFemale

    Marital Status:



    Medical Information
    Significant medical conditions: (please list)

    Current medications: (please list)

    Are you currently under the care of any psychiatrist, psychologist or counselor?

    If yes for what and how long have you been seeing your therapist:

    Lifestyle Information
    On average how often do you exercise per week?
    (e.g. walking, swimming, cycling, running, gym, yoga)

    On average your sleep is:

    On average I eat a healthy diet:

    On average how would you describe your alcohol consumption:

    Do you smoke?
    YesNoTrying to quit

    Hobbies and Interests:

    Presenting Issue*
    I would like help with:

    How long has this problem existed?

    Are you currently having (or in the past had) medical or psychological treatment for this presenting issue?

    If yes please give details:

    Have you ever had hypnotherapy before?

    If yes for what and what results did you experience:

    Do you have any questions about hypnosis?

    How did you hear about Hypnotherapy Solutions?
    Word of MouthGoogle/InternetOther (please specify below)

    By submitting this form I confirm that I am willing to be guided through hypnosis for the purposes of self improvement. I understand that the hypnotherapy I am receiving is not a substitute for normal medical care. I should continue any present medical treatment and consult my regular medical doctor for treatment of any new or existing illnesses. I accept that no guarantee of a cure can be given for any presenting issue or any issues which may become apparent during the course of therapy.

    I also agree to the following TERMS AND CONDITIONS.

    If you are running late for an appointment please contact the office as soon as possible. Unfortunately a full session cannot be guaranteed if you are late but we will try to accommodate you if possible.

    Failure to attend an appointment without notification will result in full payment of the session being due. Where the session has been prepaid there will be no refund.

    If it is necessary for you to cancel or reschedule an appointment please give 24 hour notice so that the appointment can be offered to another client. If you give less than 24 hour notice the full fee for that session will be charged.