Hypnotherapypen - Hypnotherapy Questionaire

Company Name - A Way Forward For A Brighter Future


CLIENT QUESTIONAIRE
Full Name
Address
Post Code
D.O.B
Gender
Contact Numbers (please make sure you put a current phone number as i will need to contact you.)
Marital Status
Ethnic Origin
Occupation
Medical Conditions( Past and Present)
Medicine Taking At Present
Reason For Consulting Hypnotherapist
How Long Has This Issue Been Effecting You?
What have you tried already?
Have you ever had any Mental or neurological disorder( If So Explain)
Wouold You Consider Yourself An Anxious Person? YES NO
On A Scale Of 1-10 ( 10 Being The Highest) How Much Does This Issue Effect Your Life? 1-3 4-7 8-10
Do You Wear Contact Lenses? or Have Problems With Your eyes? YES NO
Do You Have Any Fears Or Phobias ( ie Spiders- Water-Planes_ Confined spaces)?
What Are Your Expectations With This Treatment?
Hobbies and Interests
Anything else I Should Know About You Or Your Circumstances
I want you to know that all information gathered is private and confidential and as so will only be released to authorities if I feel you or another person is in personal danger.

Penelope Pedley Hypnotherapy

Helping bring freedom for

:Weight loss, Lose weight by Hypno Gastric Band, Anxiety in Children, Teachers and Pupil issues, Bad Habits, Nail biting, Phobias, Fear of Flying , Increase Sales Performance, Increase Sporting Performance, Exam nerves, Ego boosting, Pain relief, Sexual health , IBS, Panic Attacks, Insomnia, Childhood Trauma, , Performance, Habit breaking , Ticks, Bed wetting, Teeth Grinding, Confidence, Sexual Impotence, Premature Ejaculation, Sexual Performance, Anger Management and much more in

Burton on Trent ,Staffordshire (derbyshire borders).