Accredited by:


Assured Effects Hypnotherapy - NCHThe NCH represents over 1800 hypnotherapy professionals within the United Kingdom.



Regulated by:

Assured Effects Hypnotherapy - CNHC

Follow Assured Effects Hypnotherapy:

The Department of Health recommends that, when looking for a hypnotherapist, you consult with someone who is CNHC registered

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Call  today on  0800 313 4233  

Clinical Hypnosis in Poole, Bournemouth, Dorset and London

0800 313 4233

07951 159111

Client Intake Form

Client Intake Form

  • Full Name*
  • Email Address*
  • Contact Number*
  • Age*
  • Date of birth
  • Home address
    Fulll address including post code
  • Gender
  • How did you hear about us?
  • If Google - what did you type in?
  • Who is your GP?
  • How would you describe your current health?
  • Briefly outline any medication you are on
  • Do you have back or neck probelms
  • Are you in a relationship?
  • Does your partner know you are coming for therapy?
  • Do you have children?
  • Occupation
  • Occupational Stressors
    What is stressful about work (if anything)?
  • Do you suffer from general anxiety?
  • Have you ever had a panic attack?
  • Very briefly describe your problem to be resolved by hypnotherapy
  • Roughly how long have you suffered with this issue?
  • What solutions have you previoiusly attempted?
  • How would you describe your current sleep pattern?
  • How would you want to feel differently?
  • How will we know when your treatment is complete?
  • Do you have any of the follwing symptoms
  • Do you fear embarrasing yourself?
  • Do you worry that you will be judged?
  • Do you worry too much?
  • Do you fear:
  • Do you have recurring intrusive thoughts?
  • Do you continually check things?
  • Do or did your parents have similar issues to you?
  • Did your parents worry a lot?
  • Were you over-protected as a child?
  • Were your parents overly critical of you?
  • As a child were you able to express your feelings?
  • Were you allowed to cry?
  • Were you allowed to be angry?
  • Did you grow up feeling insecure?
  • Do you often feel depressed?
  • Have you ever been diagnosed with any psychological problems by your GP or others?
  • Do you ever take any non-prescribed drugs (excluding alcohol)?
  • What exercise do you take?
  • What do you do to relax?
  • When do you feel at your best?
    ie. In the morning, at weekends, out walking etc
  • What do you like about yourself?
  • Do you need to be liked?
  • Do you strive for approval??
  • Are you a perfectionist?
  • Do you procrastinate?
  • Any comments that you would like to add?
  • Security Code*