New Registration Form

    Your Name (required)

    Date of Birth

    Address

    Your Email (required)

    Mobile (required)

    Landline

    Person to contact in an emergency

    Contact’s ‘phone number

    Doctor/GP's name and address

    Do you consent to your Doctor/GP being informed?

    Are you taking any medication or have received psychiatric treatment? Please detail:

    Do you drink alcohol, if so how much per week?

    Do you smoke, if so how much per week?

    Do you take drugs?

    Are you married or in a relationship?

    Do you have children; if so what ages are they?

    What is your occupation?

    Have you had experience of hypnosis or counselling?

    What issue would you like to resolve and what would you like to achieve?

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