New Client Intake Form
Natasha James Hypnotherapy and Therapies
Clinical Hypnotherapist
NLP Practitioner

Please complete this form. Giving as much detail as possible. All the information provided will be used for the purpose of your treatment only and will remain strictly confidential.
Email *
Name *
Address *
Contact number *
Date of Birth *
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Where did you hear about me? *
Have you had any previous experience of Hypnotherapy? If yes please provide details: *
What is your reason for seeking Hypnotherapy treatment? *
How long have you had this problem? *
How long does it normally last for? *
What is your desired outcome from having Hypnotherapy/NLP? *
How will you know you have achieved your desired outcome? *
Are you currently experiencing any of the following conditions?
If you answered yes to the above health-related question, please provide details: *
Have you ever been formally diagnosed with any form of psychological or psychiatric conditions? If yes please provide details: *
Have you consulted your GP about the condition(s) for which you are seeking therapy? If yes please give details: *
Do you have any other conditions you think I should be aware of? If yes please give details: *
Are you currently taking any prescribed medications? If yes, what are the medicines names, and what do you take them for? Please give details: *
Number of cigarettes smoked a day: *
Alcohol consumption per week: (One unit = one small glass of wine/half a pint of lager/a single measure of spirits) *
Caffeine consumed per day: (E.g. number of cups of tea/coffee/energy drinks) *
Do you, or have you ever used illegal drugs: *
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