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Client Questionnaire

Please complete this assessment as accurately as possible.

All the information you provide is confidential

Personal

Where did you hear about me?

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Type Your Name

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Date of Birth

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Your Age

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years

Address

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Your Postcode

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Type Your Phone

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Type Your Email

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Emergency Contact

Emergency Contact Name

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Emergency Phone Number

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GP Name and Address

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Medical Information

Medical History including any allergies (please include approx. dates)

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Present medical conditions including pregnancy

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Medication and what it's taken for,including dosage, any side effects and including recreational drugs

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Have you experienced any mental health issues, including depression, psychosis or an anxiety disorder? Please give details.

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Have you been to see a psychiatrist, counsellor, psychologist or other type of therapy? Please give details.

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Hypnotherapy

Have you had hypnotherapy before?

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If yes, what was the outcome of your treatment / session

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Family

Are you married or with a partner?

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Do you have any children? How old are they?

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Have you experienced any major bereavements?

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Who do you live with and how is your relationship with them?

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Who was in your family unit when you were growing up and what was your relationship with them?

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Problems
Conditions

Contact between allocated sessions is usually limited to appointment changes only. I am not trained in crisis counselling and am therefore not able to offer a crisis service. Please make contact with your GP or A&E if you are in crisis. In addition, the Samaritans offer a free 24 hr, 365 day crisis service, they can be contacted on 116 123 or text Shout 85258

Confidentiality: Please see my privacy policy for more detail on your data.

Your privacy is of utmost importance. However, confidentiality may be legally breached in the following circumstances:

  • Risk of Harm: If you disclose intentions to harm yourself or others.

  • Legal Requirements: Under UK law, I am obligated to report any concerns related to:

  • The Terrorism Act 2000 – Any suspected involvement in terrorist activity must be reported to the authorities.

  • The Money Laundering Regulations 2017 – Any suspected involvement in money laundering or financial crime must be disclosed.

  • Drug-Related Offences: While personal drug use is confidential, disclosure of intent to supply, distribute, or produce illegal substances may require reporting to the relevant authorities.

Outside these legal obligations, all information shared within sessions remains strictly confidential.

If I see you somewhere outside of our sessions, to ensure your confidentiality, I will not approach you or act as if I know you, however if you acknowledge me then I will acknowledge you. Although the therapeutic relationship is friendly it is not the same as friendship, so in order to keep our therapeutic space the confidential and safe experience that you deserve, I avoid any kind of dual relationship with current and former clients.

Exceptions apply as detailed below;

Information about a child or adult, who I believe, is, or who may be at risk of, significant harm. I will seek to respect your wishes unless this may compromise the safety of the person at risk. If you disclose planned serious harm to yourself or others. I will encourage you to speak to others, such as your GP, but I may consider acting on your behalf and this may be without your consent. (And this also may be after our sessions have ended if the ending is unplanned).

Session Notes: I do keep short notes from our sessions. These notes are kept confidential.

Antisocial behaviour will cause the immediate cessation of treatment.

Nature of Hypnotherapy

Hypnotherapy is a complementary therapy designed to support emotional and mental well-being. While results vary, hypnotherapy is not a substitute for medical or psychological treatment. If you are under medical or psychiatric care, you confirm that you have informed your healthcare provider about your decision to undergo hypnotherapy.

Cancellation & Refund Policy

To ensure fairness and respect for all clients, the following cancellation policy applies:

  • 48-Hour Notice: If you need to reschedule or cancel, please provide at least 48 hours' notice and in the event of cancellation please note that a transaction fee will be deducted from the refund.

  • Less Than 48 Hours' Notice: Cancellations within 48 hours of your appointment will be charged 50% of the session fee.

  • No-Show Policy: If you do not attend your scheduled session without prior notice, the full session fee will be charged.

  • Late Arrivals: If you arrive late, your session may be shortened accordingly, and the full fee will apply.

Payment Policy

Payment is required at the time of booking unless otherwise agreed. Refunds are not provided for completed sessions.

Room Hire Policy: Face-to-face sessions held at Lake House Kent, require payment in advance to secure your booking and cover the cost of the room.

The room hire fee is non-refundable or transferable if the session is cancelled less than 28 days within the booking date. Cancellations made more than 28 days in advance will be eligible for a refund minus the Zettle transaction fee.

Thank you for your understanding.

By proceeding with your booking, you agree to these terms.

Client Responsibility:

By signing this form, you acknowledge that you are voluntarily choosing to participate in hypnotherapy. You agree to be open to the process and understand that your progress depends on your commitment to the sessions.

Todays date

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Your Name

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Intuitive Hypnotherapy