CONFIDENTIAL: Client Information and Consent Form Please complete as fully and truthfully as possible – the more detail you give, the more I can help you.
II. What You Are Seeking Help For:
1. Please give details of what you are seeking help for today.
2. Do you have any other health conditions I should be aware of? Yes/No If yes, please give details:
3. Have you had hypnotherapy before? Yes/No If yes, please give details and effectiveness:
4. Have you had any other forms of therapy before? Yes/No If yes, please give details and effectiveness:
5. What do you want to achieve from your therapy sessions?
6. How will you know when you have achieved this?
III. Your Therapy Agreement.
1. I understand that hypnosis is a way of inducing a voluntary state of relaxed, attentive concentration, during which the conscious critical mind may become more relaxed and the subconscious mind more open to suggestions and release of negative ideas, only with a person’s permission.
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IV. Terms and Conditions.
1. Session Payment. Payment by cash or bank transfer is possible. Invoices are sent by e-mail upon request.
2. Cancellations. We require you to give 24 hours notice to cancel your therapy session. If your appointment is on a Monday, please cancel on Friday.
3. Non-attendance. If you fail to attend a session without giving any notice for that session you will need to pay for that session before booking any further sessions, unless we have an alternative arrangement in place.
V. Our Privacy Policy & Your Data Protection Rights.
1. Confidentiality. Your therapy and personal information are kept securely. In certain circumstances, information, but not names, may be shared with a supervisor, or other relevant person acting in that capacity. It is my legal duty to breach confidentiality if I have concerns that you or anyone else is at risk. If this occurs I will discuss it in the session along with any recommendations and document it in your notes.
2. Information we collect about you and how we use it. Upon starting therapy, I will collect basic personal information for contact and identification reasons. During our therapy meetings, an assessment of your psychological health will be completed, and notes will be taken during sessions. These may include personal and sensitive details about your life. The assessment and notes are used solely for the delivery of a therapy service to you.
3. Your rights. You have rights relating to the information I hold to verify the accuracy or to ask for them to be supplemented, deleted, updated or corrected. You have the right to request a copy of the information that I hold about you. If you would like a copy of some or all of your personal information, please email or write to me via the contact details stated in this agreement. Information will be provided to you within 30 days.
4. Security of your data. Information will be kept securely and confidentially in line with the data retention policy as stated above.
Submit
Thank you! Information will be kept securely and confidentially.
