Woodside Practice in Cornwall - Solution focused hypnotherapy

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or contact us on 07746 727 989

Client Information Form - Pre Consulation

Thank you for enquiring about Hypnotherapy.
In order for us to be best placed to offer you treatments that are right for you,
please would you complete and submit the form below with as much information as possible.
Once we have received this form we will contact you to arrange a mutually convenient time for an initial consultation.

Please be assured that all information received is handled confidentially, sensitively and securely.

Thank you

Client Information Form

Name:

Age

Email:

Phone:

Phone 2

Address

How are we going to help you?

What would you like to achieve by hypnotherapy?

Occupation

Bought up by?

Position in family (eldest / youngest / middle etc)

Married / In a steady relationship

Yes

Partner / Spouses name

Children?

Yes

Names / Ages

Do you suffer with.......... IBS?

Migraine?

Do you recheck things?

Nail biting?

Do you think you drink too much?

Do you smoke, or vape?

Any irrational fears? ( heights, enclosed spaces, spiders, snakes etc...)

Ever had a panic attack? (fast heartbeat, hot /cold flushes, fast breathing)

Do you have difficulty getting to sleep?

Do you wake up in the night?

Do you wake up too early?

Do you have difficulty waking up?

Are you on any medication?

Doctors name

Doctors Practice

Any other information / comments

Where did you hear of The Woodside Practice?

GDPR I agree to be contacted by

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Online & Face to Face

Solution Focused

Hypnotherapy

ADDRESS *

Trelawney

Fentonadle

St Breward

Cornwall

PL30 4PJ

* visits strictly by appointment

CONTACT

07746 727989

01208 628204

info@woodside-therapy.co.uk

OPENING TIMES

Monday to Friday

09.00 to 17.00

Saturday

09.00 to 12.30

Sunday (& bank holidays)

Closed

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Results may vary from person to person