Discovering you...

Please complete as much of this form as you're comfortable with. If you would like to add anything or have any questions, please contact me at hello@rippleshypnotherapy.com

First name

Last name

Phone

Date of birth (DD/MM/YY)

Address

Emergency contact

Emergency contact phone number

Do you have children?

Relationship Status

Are there any health conditions that I may need to be aware of?

Are you taking any medication?

Please share what you'd like to work on or explore in our session(s)

Do you have any phobias or fears or things you don't like to imagine?

Do you have ongoing pain or tension (6 months or longer) anywhere in your body?

Are there any cultural, religious or spiritual beliefs I need to be aware of?

Is there anything else you would like me to know relevant to your hypnosis experience?

Please acknowledge Nicole has a duty of care to report anything that you have disclosed that may cause harm to yourself or another person

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