Woodside Practice in Cornwall - Solution focused hypnotherapy

Client Information Form - Smoking Cessation

Thank you for enquiring about Smoking Cessation with 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

GENERAL QUESTIONS...............Name:

Age

Email:

Phone:

Phone 2

Address

Occupation

Hobbies & Interests (Include Social, Physical & Creative )

When are you most relaxed?

Spouse / Partner? Name:

Smoker?

Yes

Children? Names / Ages?

Do friends or colleagues smoke?

Did your parents smoke?

PHYSICAL & PSYCHOLOGICAL HEALTH .....Good Physical Health?

Medication?

Any symptoms of smoking?

Any history of Cancer or Heart Disease in family?

Do you think you drink too much?

Use of Recreational Drugs?

Do you have difficulty getting to sleep? Wake up in the night? Wake up too early?

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

Do you recheck things?

Nail biting?

History of Anxiety or Depression?

PRO SMOKING LOBBY ................... How many do you smoke (on average per day)?

Age you started?

When do you most enjoy smoking?

What do you enjoy about it?

Why are you still smoking?

How does it help you?

What happens if you don't smoke?

Any withdrawal symptoms?

Have you stopped in the past? How long for?

If applicable, what was the situation in which you started again

ANTI SMOKING LOBBY ............ How long can you go with out smoking?

On Planes?

In Cinemas?

Sleeping?

Meetings? / At Work?

What do you dislike about smoking?

What health issues are you afraid of?

What are you most looking forward to about being free from smoking?

EXPECTATIONS .......... How do you think this process will help you?

Any previous experience of hypnosis?

Any other information / comments

Where did you hear of The Woodside Practice?

GDPR I agree to be contacted by

Solution Focused

Hypnotherapy

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