Hypnotherapy Form | Ripples Wellbeing

First name

Last name

Gender/Preferred pronoun

Date of birth

Address

Phone

Do you work with any other agencies?

(e.g. social worker, mental Health support, other support/counselling services)

Your GP (name and surgery)

Name and telephone number of next of kin (that we can contact in case of emergency)

Previous experience of hypnotherapy / mental health support / issues

Do you have any medical conditions or health concerns? Please also list any medication you are taking

Please set out any accessibility requirements you may have

Further information For us to ascertain if hypnotherapy is suitable for you, please answer the below questions honestly and as fully as possible:

What is the main reason for seeking hypnotherapy and how is the issue you wish to address affecting your daily life?

What support (if any) has already been put in place for you regarding the issue you wish to address (home/work for example)?

On a scale of 1 – 10 (10 being the most), how important is it for you to resolve this issue, and why?

Please let us know your availability (the more flexible you can be, the earlier we may be able to book you in)

Fees/Payment

The cost of the Initial Consultation Session is £35 and shall be collected in advance*

The cost of Hypnotherapy Sessions (all sessions after the Initial Consultation) shall be £65 and shall be collected in advance*

Payments are to be made at the time of booking the appointment in advance via the Calendly link on our website*.

Following the initial consultation session there is an option to block book sessions at the cost of £180 for 3 sessions.

We reserve the right to not continue if payment has not been made in advance of your session.

* Unless otherwise agreed with Ripples Wellbeing management

If you are within the low-income category, please contact us to discuss what options are available.

Signing this form means you agree to the following:

I agree to this referral and to sharing this information with Ripples Wellbeing and the Hypnotherapist
I understand that hypnotherapy is not a substitute for qualified medical advice and/or treatment.
I understand that there is no guarantee in relation to the outcome of hypnotherapy treatment.
I understand that the hypnotherapy treatment shall require my effort and honesty to achieve the best possible outcome.
I agree to information sharing with partner agencies when necessary.
I agree to secure storage of my personal details.

Signature

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