Appointment Form — Heid Hypnotherapy

Pre-appointment form

Name

First Name

Last Name

Email

Phone

Emergency Contact Name

Emergency Contact Phone Number

Do you require permission from your GP or mental health team to have hypnotherapy?

Yes

No

Unsure (please discuss in consultation)

GP Surgery name and telephone number

Conditions currently in active treatment for

Medication currently taking

Do you know of any reason why hypnotherapy may be a risk to you?

I give consent to hold information for treatment reasons under the GDPR

Yes

I have read and agreed to the Hypnotherapy Agreement

Please complete this form before your first hypnotherapy session.

The information requested in this form is considered necessary for ensuring safe treatment.

A word version of this form is available from katiegerrard@heidhypnotherapy.com

Permission to store information related to yourself and your treatment allows me to make notes which helps me plan each session. It will be held according to GDPR regulations.

You can find the Hypnotherapy Agreement here