Registration Form

Name
Age
Date of Birth
Address
Email
Mobile
Landline
Person to contact in an emergency:
Contact’s ‘phone number:
How did you hear about KarenBoxall-Hypnotherapy, Counselling & Mentoring?
Doctor/GP's name and address
Do you consent to your Doctor/GP being informed?
Are you taking any medication? Please provide details and reason for taking them.
Do you, or have you, suffered from an eating disorder, e.g. Anorexia, Bulimia?
Do you suffer from any medical or psychological conditions? Please detail.
Have you had experience of hypnosis, counselling or received psychiatric treatment?
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?
What issue would you like to resolve and what would you like to achieve?