client intake form

Full Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	County
Postal / Zip Code	Country

Phone Number *

Area Code Phone 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?

Would you be interested in details of the Trust Transformation therapy & coaching package?

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 GP A counsellor Another therapist

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.

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. Reply of form denotes signature has been offered.

2. Date

Chosen payment method: Paypal, BACS

Would you like a Pay Pal invoice sending to you?

Payments accepted:PayPal (rosalynpalmer@btinternet.com), Bank Transfers, cash by prior agreement for face to face sessions. A deposit of 20% is required upon booking (and no later than 72 hours prior to the session) to secure the booking. For Zoom/Skype sessions, full payment a minimum of 72 hours in advance of the session is required. Invoice can be sent upon request. Cancellations of less than 72 hours before sessions will make the deposit non-refundable or in the case of Zoom/Skype the full session payment. Email reply denotes acceptance of these terms.

Skype address if appropriate

enquiries@rosalynpalmerhypno.com

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