Thank you for enquiring about Hypno-Analysis

This online assessment form is an aid to predicting your suitability for Hypno-Analysis. It can save time at your session. Please answer the questions below honestly as they will help me to predict your suitability for the process and increase the success rate of your therapy.

All information requested is used only in your assessment and treatment. No information is used by or sold to a third party for any reason. All communication is confidential and private.

or just contact me via my email or mobile 07940029383 to arrange a free initial consultation

email address : info@openpalm-hypnotherapy.com

 

Online Hypno-Analysis Assessment form

Please answer the questions honestly

This should only take a few minutes to complete

Please add your full name

Please add your email address

Please add your contact number

Preferred method of contact

Phone  Email

About you

Your Date of Birth  DD/MM/YYYY

  example - 10/01/1980

Gender

Male Female

Marital status

Are you Single   Married   Long term relationship

Have you any children ?

Yes    No   

If you are in a relationship are you happy in it ?

Yes No

occupation

Reffered by :

G.P.    Friend    Family member    Internet enquiry

If G.P. refferal please give G.P. / Practice details -please type in the box below

Presenting Symptoms - please type in the box below

Disclosures - anything you think may have an influence on your symptoms or treatment ?

Previous or on-going therapy/treatment

Any other further information

Thank you for your time please submit this form

* Please note that all information on this form is confidential and will not be passed on to any third party.

 

Matthew Smale Registered Hypnotherapist No. 81846

Privacy - copyright 2011 - weblinks