7PF Ltd - Client Intake Form (0425)

This form captures the key information required before each session

First name

Last name

NB - If you do not enter an email address, you will not receive the automatic reminders

Birthday

Day

Month

Year

Marital Status

Do you have children?

Occupation

This is key for me to understanding any underlying issues

Emergency Contact

Emergency Contact Details

What is the main reason for your session? eg aches & pains, insomnia, stop smoking

What score would you give the reason above? How do they make you feel? Add a number from 1 to 10

1 = doesnt bother me, 5 - I tollerate it, 10 - Constantly bothering me, in pain, had enough!

What would success look like to you? eg how would you know if our sessions had worked?

Medical History

Please share any medical history before the sessions.

*If you suffer from epilepsy, psychosis, learning disabilities or suffer from suicide ideation, please supply written permission from your doctor before we can proceed.

What is the current status of your health?

Do you suffer from any of the following? Tick all that apply - *If you suffer from epilepsy, psychosis or learning disabilities, please supply written permission from your doctor before we can proceed.

Have you been diagnosed with any mental health condition? If so, please provide details below or mark N/A

Are you currently seeing another therapist/practitioner/physician?

Yes

If yes, please enter the name of the therapist/practitioner here

Please list any current medication you are taking or N/A

Do you suffer from any allergies? If yes, please list below or N/A

Please list any treatments you are currently receiving or N/A

Are you or could you be pregnant?

Yes

Maybe

Do you have any injuries or pain anywhere in your body eg problems lifting your hands? (or N/A)

Please list any surgery you have had (or N/A)

Tinnitus - if you answered yes to the questions above, please provide further information

If 'other' please provide further details

If you have received treatment for the above issue(s) previously, what was the outcome or N/A

Do you have any fears of phobias? If yes, please list below or N/A

Do you have any compulsive habits ? If yes, please list below or N/A

Do you have any disabilities? If yes, please list below or N/A

About Your Pending Appointment

What is your understanding of hypnotherapy?

Do you have any further questions or comments?

If 'referral' please add their name here

For online VIDEO meetings, I use Google, I will not call you via your mobile or landline numbers. All online calls are VIDEO calls

Here are some handy tips to allow you to enjoy the session

Use headphones if possible to achieve the most immersive experience

Please ensure the following to enable you to have an uninterrupted session for 1-2 hours, depending on the session

You may respond by crying, shouting, laughing, etc., which is perfectly fine and normal. However, if you have others in the house during an online session, please make sure they are aware
A comfy chair or somewhere to lie down. You will need to hear my voice and I will need to see you, to monitor any movements etc.
Ensure the sun will not be shining in your eyes at any time and make sure there is a light on if we are working together late afternoon/evening
A timer is handy to set for 2hrs as should you feel sleepy after the session, this will wake you up
Always drink plenty of water before the session
Warm clothes, slippers or a blanket as you may get chilly
I may need to see your hands placed on your lap, depending on the type of session, so have additional cushions to hand
Try to wear different colour clothing to the cushions used eg if you rest your hands on black cushions and you are wearing a black top, sometimes it's difficult to see if your hands are reacting (if relevant)
Comfy cushions
Turn off all phones, electrical devices and any other device that may interrupt the session
If you are attending The Wellbeing Clinic, the above will be catered for, please refer to the 'handy reminder' re parking and tickets
Use this link to print off a handy reminder of the above

Terms & Conditions

I understand that results will vary and are not guaranteed. This is NOT a replacement for medical treatment, psychological or psychiatric services or counselling. I understand the 7 Purple Feathers Ltd practitioner does not treat, prescribe for or diagnose any condition. I understand the practitioner is a facilitator of the processes used in the session and is not practising any other profession that requires a license under the laws of England. I have agreed to participate in each session to the best of my ability. I am over 18 years old.

All U18s must be accompanied by a parent or guardian unless the parent or guardian provides written confirmation for their U18 child to undergo hypnotherapy. Ticking the relevant box below and 'accepting' the terms and conditions confirms you have read and understood

The above is an accurate representation of the required background information as requested. I understand the session is completely confidential unless the practitioner feels that I or someone else may be in danger, in which case, disclosures will be kept to a minimum, necessary for my protection or the protection of a 3rd party

All data is to be managed as per the GDPR UK rules and regulations. All data is strictly confidential.

7 Purple Feathers Ltd reserves the right to decline any sessions without providing a reason

I agree to the terms & conditions

I have read and understood that I need to be acompanied by an adult or guardian if under 18 years old, unless otherwise agreed with 7 Purple Feathers and a guardian/parent

Yes, subscribe me to your newsletter. Please 'uncheck' the box if not required

Please sign or type your name as confirmation the above information is correct to the best of your knowledge

Signature field is empty.

Date picker