Therapy Questionnaire

First Name

Last Name

Telephone

Address

Address Line 1

Address Line 2

City

Postcode

Are you on any medication?

Please tick which of the following if any you suffer from

Breathing problems

Heart problems

Migraine or epilepsy

Depression or any other kind of emotional illness

Have you seen a hypnotherapist before?

Please describe how stress, anxiety, confidence affects your life

Do you sleep well?

How would you like to feel?

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