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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