Client Form - Emma Kirkham Hypnotherapy
Thank you for joining me on your transformation.

I'm really looking forward to helping you make the changes you want to see.

Before the first session, please fill in the form below.

Forms need to be completed at least 48 hours before the first session can take place.
Email *
First and Last Name *
Age *
Full Address *
Telephone number *
Marital Status *
Number of children *
Occupation *
Are you currently taking any medication- if yes, what? *
Have you ever had psychiatric treatment? *
Do you have any physical/mental conditions? *
Do you have ADHD /Autism (diagnoses or suspected) *
Have you recently gained/lost weight? *
Have you recently consulted you doctor? *
Please select the following symptoms which feel like a problem to you at the moment *
Required
Please add any other symptom/ problem here or add anything you feel is important for me to know *
If you could release the procrastination how would life look like for you- please answer in as much detail as possible *
How will you know this has worked ? What will you be doing differently - what would you like to see happen for you ? Again please answer in as much detail as possible *
On a scale of 1-10 where 1 is the least and 10 is the most- where are you on this scale with procrastination? *
Please confirm you do NOT have epilepsy or a psychiatric condition *
For the best experience I advise you to sit somewhere where you will be undisturbed and that your head will be supported.

I also advise the use of headphones where possible.

Please confirm you give consent for hypnosis *
Signature  *
Thank you for completing the Client Form- I look forward to helping you further.

Emma 
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