Your Name (required)
Date of Birth
Your Email (required)
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?
Send us an email and we'll get back to you, asap.
Questions, issues or concerns? I'd love to help you!