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

Relationship Status

Do you have children?

Emergency contact

Emergency contact phone number

Have you given birth in the last 12 months?

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

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

Please list any medical practitioners you're seeing (name and phone number) that may be relevant to our sessions:

Would you consent to Nicole contacting them to support your hypnotherapy sessions if the need arises?

Are you taking any medication?

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?

How long has this issue been presenting?

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 may refer you to another therapist or medical professional, if necessary*

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