Private Client Enquiry Form
If you are interested in working with me privately 1-to-1, please complete this confidential form. It takes 5-10 mins to complete.The more I can understand about you and your particular needs, the more effectively I can explain how I can help you reach your goals. This form does not commit you to anything at this stage. Thank you Dr Emma Rae Rhead
First Name (s) *
Surname *
Town or City *
County or State *
Your current age *
To which gender do you most identify? *
Mobile Telephone Number (please include country code if not UK) *
WhatsApp Number, if different (please include country code if not UK)
Email Address *
What is your current occupation? *
Please describe your current problem or difficulties *
When did this problem start and how has it developed over time? *
What have you already tried to solve this problem, and what were the results? Please let me know about any past or current psychotherapy, counselling, coaching, online program, medical help or complementary health support you have received. *
On a scale of 0-10, how distressing is this current problem to you? *
Not distressing at all
Extremely distressing
How is this problem negatively impacting on your life? What is it costing you to have this problem in your life? (consider your quality of life, health, peace, relationships, career, finances, success, happiness etc) *
What are your goals? What would you wish to achieve by working with me? *
What do you feel is the main obstacle that has prevented you reaching your goals to date? *
On a scale of 0-10, how ready and motivated are you to take action to achieve your desired goal(s)? *
Entirely unmotivated
Extremely motivated
Are there any stresses or challenges in life that may make achieving your desired goal more difficult at this time? Tick all that apply *
Required
Do you have any health problems, other than you have already shared ? If so, please detail *
Have you ever been diagnosed with, or suffered from, any of the following? Tick all that apply *
Yes
No
Depression requiring hospital stay
Self harm (cutting)
Personality Disorder
Schizophrenia
Psychosis
Bipolar Disorder
Attempted Suicide
Alcohol or Drug Addiction
Dementia
Epilepsy
ADHD
Autism
Please give additional details here, if you wish
On a scale of 0 to 10, how anxious do you feel on an average day at the present time? *
Not anxious at all
Extremely anxious
On a scale of 0 to 10, how low or depressed do you feel on an average day at the present time? *
Utterly depressed
Extremely happy
Are you currently pregnant? *
Are you currently taking any medication from your doctor? If so, please list including doses *
Have you ever had hypnotherapy or hypnosis for any issue? If so, please detail *
Is there anything else you wish me to know about you?
Live sessions are currently delivered online via Zoom. I am not offering in person sessions at this time. Is this okay with you? *
Required
Please let me know your availability for live sessions. *
In a world full of therapists and coaches, why are you considering working with me? *
Where did you first hear about me and my work? *
Required
Please confirm that you have read and agree to my privacy policy here https://www.chesterhypnotherapy.co.uk/privacy-policy *
I confirm that the above information is accurate to the best of my knowledge. *
Todays Date *
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