Stop Smoking Hypnotherapy Registration Form

Note: This information is confidential

Intake Form - Stop Smoking Treatment

Name

Date

Date of Birth

Age

Gender

Phone Number

Is it OK to leave a message?

Yes

Address

Address Line 1

Address Line 2

Town

County/City

Postcode

Country

How did you hear about me?

What do you smoke? ( cigarettes / cigars / cannabis / e-cigs etc)?:

How much do you smoke?

When did you start smoking?

Any previous experience of hypnotherapy?

Why do you want to quit?

To ensure the most effective treatment, it’s important for me to understand any underlying issues that may affect your smoking habits. Please indicate if you are currently struggling with any of the following: Anxiety, Depression, Stress, Other mental health concerns.

Disclaimer, Terms and Conditions

Before you book an appointment, it’s important to understand the nature of hypnotherapy and the variability in individual results.

1. Hypnotherapy is a tool for self-improvement and not a magical solution. The process facilitates access to your subconscious to help bring about change. The therapist does not “fix” your problems or provide direct answers; instead, the resolution you seek comes from within your own understanding and resources.
2. Individual results vary: Each person responds differently to hypnotherapy, which means the effectiveness and the number of sessions required can vary greatly between individuals. While many of our clients have reported positive outcomes, please understand that results cannot be guaranteed.
3. Collaborative process: Success in hypnotherapy requires a collaborative effort. The outcomes will depend significantly on your mindset, participation and commitment to the process.
4. Hypnotherapy is intended as a tool for self-improvement and is not a substitute for medical treatment, psychological or psychiatric services, or counselling.
5. Cancellation Policy: Please be aware of my cancellation policy, which requires 24 hours notice to reschedule or cancel an appointment without charge.

By agreeing to proceed with my hypnotherapy services, you acknowledge that while I strive to provide a beneficial service, outcomes and the number of sessions required can vary.

Terms and Conditions: By registering and signing this form you are agreeing to the terms and conditions set out on my website: www.cityhypno.co.uk/terms-conditions/

Please sign to confirm you have read, understood and accept my terms of service:

Sign Here

I consent to having this website store my submitted information

Susannah Saunders

Hello, my name is Susannah. I am a clinical hypnotherapist and life coach in London with over 20 years of experience helping people to enjoy a happier, more fulfilling life. Get in touch to find out more or book an appointment in London today.

Stop Smoking Hypnotherapy Registration Form

Susannah Saunders

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