Client Information:

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Marital Status

Contact Telephone Number

Preferred Method of Contact

Phone, Email, Text Message

Occupation

What is your primary reason or goal for your visit?

Please list all medical conditions

e.g: asthma, diabetes, migraines, vertigo

Please confirm if you have any history of mental illness e.g.: depression, stress/anxieties, bi-polar

Yes

If Yes please provide details

Please detail any and all medication you are taking

If none please write NONE

Are you currently under a doctors care for these conditions?

Yes

If Yes please provide details

If Yes, Date of your last visit with doctor:

YYYY

Doctor name

Doctor Contact Number

PLEASE DO NOT INCLUDE ANY SPACES

Note

Family History: Is there any history of mental illness within your family e.g: depression, suicide, anxiety?

If Yes, please give brief description

Have you recently had or are having suicidal thoughts?

Yes

Have you ever been hypnotized before?

Yes

If Yes, please give brief description of your experience

Do you meditate?

Yes

Please note ways in which you relax and/or a place that holds happy memories for you

List three colours you like

What is your favourite season?

List any fears or issues

What kind of weather do you like the best?

Please list at least three benefits that you would feel by making the change/s that we are working on

List three of your pastimes or hobbies

Complete this sentence: I am happiest when ...

What do you want the outcome to be from your sessions?

If you were to wake up tomorrow and all symptoms/Issues had disappeared how would life be?

Participation Agreement: I acknowledge that in order to be successful in reaching my goals I must accept that the following are Important to the process: I understand that my health and well-being depend on how well I care for myself physically, emotionally and intellectually. I acknowledge that I am responsible for my experience of life as I make the choices and take the actions which shape my life. I agree to be an active participant in my therapy process and see myself as an equal partner in the success of the process. I agree that I am 100% committed and ready to change and achieve my goals. I will be on time for all sessions.

CLIENT SIGNATURE

Date

YYYY

My Commitment to You: As a client you must be 100% ready to change and achieve your goals. I agree to use my abilities and expertise to facilitate such changes as are mutually agreed to be in your best interest. I am professionally committed to assisting you in using all your resources to achieve your goals in the shortest possible time. Therapist Signature: ANNIE KÈKI

For office use only

Data Protection Policy

Therapy Agreement The Clinical Hypnotherapy Process Hypnotherapy uses the power of suggestion to create changes to our thoughts, feelings and behaviours. The process itself alters your state of consciousness in a way that works with the subconscious part of your mind. During this process, your heightened sense of awareness Is able to accept positive suggestions. Hypnosis is very natural. You will probably enter hypnosis several times a day when you are engrossed in a task or just as you are falling to sleep. Clinical Hypnotherapy is not to be confused with stage hypnosis. You are in control at all times. We will go over your consultation form and discuss what you are hoping to gain from therapy. We will discuss options of which therapy will suit you the best and how many sessions you may need. It can be helpful to agree to have regular reviews to discuss how you feel your aims are being achieved. If our work together highlights a specific need outside of my training and expertise It may be necessary for us to consider referral to another specialist therapist. If this becomes apparent, we will discuss it together and decide on the best way forward for you. Professional boundaries The relationship that develops between us is an important part of the process. Part of what enables the process to work is the maintenance of boundaries between us. It is therefore not helpful to allow our therapeutic relationship to have the features of a friendship, such as me sharing too much about myself, exchanging presents or contact between sessions. Should you need to contact me to arrange additional sessions or rearrange an appointment time please leave a message on my answer phone and I will return your call when I am able. Confidentiality As a registered member of the General Hypnotherapy Register (GHR) I abide by their Code of Ethics. Everything discussed between us is kept confidential. The exceptions to these are if: I believed you or someone else was at risk of serious harm. I hear of harm or abuse to a child. I am ordered by a court of law. I become aware of an act of terrorism If I believe you are at risk of harming yourself, I will consider contacting your GP. I would make every effort to discuss any concerns I have with you first. In accordance with best clinical practice, I discuss my work with a counselling supervisor. My supervisor is bound by the same code of confidentiality and ethical framework. Data Protection Act Any personal details I keep are stored securely. Under the terms of the 2018 Data Protection Act you must give your consent to such information being made and retained. By signing the agreement, you are giving such permission. Missed appointments and late arrivals The duration of sessions may vary. Should you arrive late for a session I will not be able to extend the session beyond our original scheduled ending time as I may well have another client due. If you need to cancel a session for whatever reason I require 48 hours notice in order to avoid payment of my fee. One other session date will be offered as an option. On the rare occasion that I am unable to keep our appointment I will give you as much notice as I can, and I will not expect payment of my fee. Fees £75.00 per therapy session, if an audio is deemed helpful following a session, this is included in the session fee. If booking a block of sessions therapy fees will be agreed at the time of booking. Receipts can be provided. Feedback of any nature is welcomed.

ANNIE KEKI

CLIENT'S SIGNATURE

Date

YYYY

Thank you for completing your consultation form. As soon as I have considered it I will be in touch to discuss the way forward. If you have any questions, please contact annie@iamme.guru

Much Love,

Annie -x-

Consultation Form

Inspiration

I AM ME…

annie@iamme.guru