Client Information Form - Hypnotherapy

This form collects personal data (information) to help me to prepare for your therapy session. If you are not able to complete the form online please contact me. I can send you a printed version to return to me by post at no further charge. Or I can arrange to interview you on the phone or by Google Meet to complete the form for you, but a nominal charge will apply to cover my time. 


GDPR

Please read our privacy policy here: https://www.thewellbeingtherapyhut.co.uk/blank-page-1. This tells you how I collect, look after and use your personal data. Under the GDPR, (Data Protection law) I need you to agree to each separate use of your data by ticking all available options. You can withdraw consent at any time by letting me know in writing.

Sign in to Google to save your progress. Learn more
GDPR - I have read your privacy policy and agree to you using my personal data: *
Required
Name: *
Date of birth
MM
/
DD
/
YYYY
Address: *
Email: *
Best contact phone number: *
Name and phone number of someone that could be contacted in an emergency: *
GP Name and Address:
How did you hear about this service? *
Have you previously received any type of psychological therapies (e.g. psychotherapy, counselling)?
 *
Required
Have you ever been diagnosed with any of the following? (Please tick all that apply)
 *
Required
Are you currently taking any prescription medication?
 *
Have you ever had suicidal thoughts or tried to harm yourself?
 *
How would you rate your current sleeping habits?
 *
Poor
Very Good
Who lives in your household? (Please give names, relationship to you and age if under 18)
 *
Are you ...
 *
What do you do for fun, or to relax?
 *
How healthy is your diet?
 *
What is your smoking status?
 *
Have you ever taken recreational drugs?
 *
How often do you drink alcohol?
 *
What exercise do you do in an average week?
 *
How high are your stress levels?
 *
How good is the support you get from family and friends?
 *
Have there been any big changes in your life in the last 12-18 months? (e.g. home, work, family)?
 *
Do you suffer from any fears or phobias (other than something you are seeing me for)?
 *
What are your goals for the therapy?
 *
If there's more than one thing, what's the most important?
Location preference for sessions
Clear selection
When is the best time for sessions?
Do you have any personal connection to current TWTH clients or counsellors?
If there is any other information you'd like to give that didn't fit on the form, please put it here.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of The Wellbeing Therapy Hut. Report Abuse
Google Forms