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