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Leah Jung Clinical Hypnotherapist consultation and consent form, Adult and child. 
PRIVATE AND CONFIDENTIAL  Leah.hypnotherapist@gmail.com       T.Jung DHP Acc.Hyp. HWFP, PHPA, HS, GQHP,  GHR, MHS , Professional Standards authority accredited register. ICO REGISTRATION REF: ZB310349

Space to be you 1st floor, mare street wing, St Joesph's Hospice, London E8 4SA

Tel: 07939 342990
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Email *
Address ( If you like to put address)
Name *
Date *
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Telephone phone
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Age/ matial status and number of children *
Hobbies/Interest *
Occupation *
Names of best friends? *
General Health *
Date of last physcial exam, at doctors/Hospital *
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Any noticeable findings? *
Currently in treatment? And any medications and dosage that you are currently taking?
Duration of Symptoms *
Previous Treatment for this problem? *
Fears / Phobias *
Any compulsive habits?
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Do you ever suffer from asthma or allergies? *
Have you ever suffered from depression? When ? *
Have you suffered from epilespy im the last 2 years? *
Have you ever had a treatment from a Psychologist/Psychiatrist/Therapist If Yes please provide details? *
Contra consultation  ( If you have any of these please consult with Gp and a letter to say they are in agreement with Hypnotherapy session to go ahead) *
Have you ever been hypnotised before?
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Where did you hear of this practice? *
Do you use any social drugs? *
Your family's history may be of value, Check any following to your blood relatives. *
Required
Common difficulties, please check what applies to you. *
Required
Are you currently taking any drugs/ medication? *
What would you say is your main concern at this time?
In hypnosis sometimes I may tap your shoulder or finger or lift your arm is this okay with you?
 *
Describe your favourite place or scenes which symbolise to your good feelings such as peace, contentment or relaxtion. Focus on ther sights, sounds, smells, temperature, movement, tastes. Feeling on your skin, (wind, clothing etc) and any other sensations or emotions each scene evokes in you. *
Details of major operations? *
Doctors Name and address and Number
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Have you got any type of psychosis?
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If you have any psychosis,  bi polar, Schizophrenia, Hallucinations, delusions, thought disorder, Have you spoken to the doctors, will need a letter to accept working with you. *
Consent to hypnosis signature child and parent.  *
Date:
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