Questionnaire for new clients

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1. Terms and Conditions
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Voluntary Consent to Participate

The Client voluntarily consents to participate in the therapy services provided by Practitioner. Methods used in this program may include: hypnosis, virtual reality therapy, coaching, guided imagery, relaxation training, visualization, Neuro-Linguistic Programming, exercise guidance, nutritional guidance, involvement of  mindfulness and cognitive behavioral therapy. All such processes are hereafter referred to as “services.”The Client agrees to be an active participant in the program and shares responsibility for the process and results. The Client understands and agrees that the practitioner’s services will address only the mutually agreed upon and specified concerns. The Client agrees to inform the therapist of changes in his / her circumstances or medical status that may adversely affect his / her ability to participate fully in the program.

The Practitioner agrees to render ethical, competent services to the Client, to the best of his / her abilities and within the limits of his / her professional knowledge and training. However, the Client understands that the Practitioner’s services are not based on exact science and that the results can vary among individuals. The Client understands and agrees that there are NO GUARANTEES as to the results or outcomes. The Client remains ultimately responsible for his / her own decisions, actions, choices, and emotions, during and after participation in the program.

The Client understands and acknowledges that the services to be rendered may consist of a variety of processes and may incorporate questions, visualizations, pretending, writing or drawing, role-playing, breathing instructions, eye-movement instructions, take-home assignments, and physical movement. Procedures will be explained to the Client in advance and will be conducted only with the Client’s consent. The Client has the right to ask questions about any process and to discuss any concerns before, during, or following these processes. The Client has the right to accept or reject instructions, advice, interpretations, or suggestions made by the Practitioner at any time. The Client understands that the noncompliance with program instructions may reduce the probability of success.

Confidentiality and Privacy

The Practitioner will not release any information to any one without a written authorization from the client, except as provided by law.

Fees

Individual session cost £70, however, in case of financial difficulties the price might be £55. I can provide a variety options how your session can be funded.

Number of sessions can be more than what is given from voucher; this depends on a goal you want to achieve. You will be given 7 days notice of any change in fees. You can pay by card, cheque or in cash in advance or after the session but no later. However, the first session has to be paid by cash. If you have had the voucher, then a number of sessions and price given in voucher is set since the beginning of the treatment then thereafter another session is for a price in this paragraph. Payment for services is paid in full on the date of each session.

Please read a full version of terms and conditions at www.ihypnosis.org.uk/client-bill.pdf
 
By sending of this questionnaire you agree with full version of terms and conditions.

1. What is your full name? *

 

2. What topic or your goal with using of hypnotherapy would you like to achieve? *

 

3. State in your own words the nature of your main problems and their duration:

 

4. With whom have you previously consulted about your present problem(s)?

 

5. What sort of work are you doing now?

 

6. Does your present work satisfy you? (If not, in what ways are you dissatisfied?)

 

7. Present interest, hobbies and activities:

 

8. How is most of your free time occupied?

 

9. Which of the following words apply to you:

YesNoMaybeNo answer
worthless
useless and "nobody"
"life is empty"
inadequate
incompetent
naive
"can't do anything right"
guilty
hostile
anxious
agitated
unassertive
panicky
aggressive
unattractive
unloved
misunderstood
bored
restless
confused
unconfident
in conflict
full of regrets
worthwhile
sympathetic
intelligent
attractive
confident
considerate
assertive
headaches
financial problems
fainting
palpitations
dizziness
no appetite
bowel disturbances
stomach trouble
insomnia
nightmares
fatigue
alcoholism
feel tense
take sedatives
tremors
unable to relax
shy with people
take drugs
don't like weekends
can't make decisions
don't like vacations
can't make friends
over rambunctious
can't keep a job
disoriented
unable to have a good time
concentration difficulties
memory problems
 

10. Do you have any diagnosis determined by psychiatrist or have you got prescription from your GP to use antidepressants?

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