Client Intake Form

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

City

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

E-mail*

Date of birth

Marital status

Occupation

Doctor's name and address

Date of last check up and any medications being taken

What issues concern you?

What are the top 3 issues that are bothering you? And why do you think you have them?

Any additional information you would like to give?

What are the top 3 changes you'd like to make in your life? Include the positive end results, such as how you would feel and how your life would look.

If I had a magic wand and could take one issue away immediately what would it be and why do you choose it now?

Have you had hypnotherapy before? If so when? What was the result?

Have you had other forms of therapy before? If so, what and when?

How did you hear of or discover Rosalyn Palmer?

Any additional information regarding how you would you like to feel/behave once this issue is resolved or why it remains?

Are you currently under the care of:

Your GPA counsellorAnother therapistOther

Which treatment would you like to book?*

Advanced transformation therapy (One RTT session)Three RTT sessionsTrust Transformation PackageTwo Session Package - 6 weeks

Do you qualify for the reduced rate T &C's? Please indicate if you do*

Terms and Conditions concerning hypnotherapy: Rosalyn Palmer offers Rapid Transformational Therapy (hypnotherapy) using the Marisa Peer Method. For some issues, one session is sufficient but for others to be addressed it requires two, three or more sessions that cannot be predetermined until the first session. Hypnotherapy is entirely safe, natural and relaxing. You will remain conscious and in complete control throughout. In hypnotherapy, regression is used to help discover the root cause of the issue with a view to changing it. Please note that the use of hypnotherapy alone is no guarantee of success. The client needs to want - and be open and motivated - to change or improve their area of concern, via the use of hypnosis. The recommendations by Rosalyn Palmer are not intended to substitute any diagnosis and care by a qualified GP. If you are under medical care for any condition do not make adjustments to prescribed medication without the approval of your GP. If in any doubt seek your GP's advice. For Zoom sessions additional pre-registration information will be provided.

Terms and Conditions concerning three session hypnotherapy packages: Once first session has taken place,a package is non-refundable. It is transferable under mutual agreement to a third party or a transference of therapy and coaching sessions one for the other. Any negotiations to a past package, once commenced, will be subject to an admin fee. Once commenced the package must be completed within six calendar months from that date at which time it will expire. A no-show is deemed to be cancellation at less than 48 hours notice or not attending a pre-arranged session. This will count as a spent session.

Terms and conditions concerning the Trust Transformation package. Once commenced the package must be completed within six calendar months from that date at which time it will expire. In addition to this, the Terms & Conditions relating the to three session hypnotherapy package also apply.

Client agreement. 1. Signature

I can confirm that I have read the above and understand the process of hypnotherapy and accept these terms and conditions. Return of form denotes signature has been offered.

2. Date

Chosen payment method: Paypal, BACS

Would you like a Pay Pal invoice sending to you?

Payment terms:PayPal (rosalynpalmer@btinternet.com), Bank Transfers, cash by prior agreement for face to face sessions. Please note that payment via PayPal will incur an additional 2.9% admin fee that is added to the PayPal invoice. For all sessions, full payment a minimum of 72 hours in advance of the session is required. Invoices can be sent upon request. Payment plans can be arranged by mutual consent. Email reply denotes acceptance of these terms.

Please send all enquiries about this form or hypnotherapy treatment to hello@rosalynpalmer.com.

Client admission form: Rosalyn Palmer - Advanced Rapid Transformational Therapist/Clinical Hypnotherapist.