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lets Sit and Talk Hypnotherapy forms
client information and consent form
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Email *
Thank you for choosing Lets Sit and Talk Hypnotherapy
First Name *
Last Name *
Age *
Date of Birth *
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Occupation *
Address *
Phone Number *
E-mail address *
Relationship Status *
Please describe your family, number of years with your partner, number of children and their ages, number of siblings and birth order. List any relevant information about your family that may impact the issue that we are working on? *
Are you currently receiving treatment from a doctor or another practitioner? If yes, give details please. *
Are you currently taking any medications? If yes, please add details. *
Have you ever been hypnotized? *
Is there any illness, distress or other concerns in your history that is relevant to your session that you think we should know about. Please give details. *
What are you wanting to address and achieve from your RTT session? Please be as specific as possible. *
If you were free from the issue you present with, what would it mean for you? How would your life be different? *
How long has this been an issue? *
How does this issue affect you, your family, your work, your hobby and your leisure life? *
What have you tried to do to solve this issue in the past? *
What worked? What didn't work? *
How does this issue make you feel about yourself? *
Which of the following seems to be a reoccurring thought? *
If I were to wave a magic wand, what is the one thing you would have me change right now? *
How high is your motivation to act and achieve the change you desire on a scale from 1-10? (10 being the strongest motivation) *
Low motivation
Strong motivation
On a scale of 1-10, how ready are you to let go of this issue? *
Not Ready
Very Ready
Is there anything else you would like me to know *
Do you or have you in the past struggled with any of the following: *
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By typing my name below, I am electronically signing this form and I understand that an electronic signature has the same legal effect and can be enforced the same way as a written signature.
I hereby give consent to Lets Sit and Talk to have my personal information to have a better understanding of my problems. I have paid my full amount that has been asked for before my session has started. I understand that my Therapist is Licensed and is legally allowed to work within Canada and internationally. Any disrespectful behaviour or any type of abuse will not be tolerated and  will lead to immediate and permanent dismissal of the client.
There are "No" refunds for any of your sessions for this is a Therapy session.  We guarantee results after 1-3 sessions but every client and issue is different. Some problems will require more than 1-3 sessions. The amount you are paying is per session and there are extra  charges for Coaching, Which is made available to you.      Sign Here:
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