Application form | ISHypno

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Application form

Please confirm the following details:

(Your data is held securely under EU data protection laws)

What can we help you with? (It can be more than one thing!)

What would be a good outcome for you? (What will it look like when you are feeling better?)

First name

Email

Age

Occupation

Partner's name (if applicable)

Last name

Phone

Your current address

Hobbies/interests

Children's names & ages (if applicable)

(It's helpful to have the names of these significant people who you may speak about often!)

Doctor's name (if known)

Address of your Doctor's Practice

Do you suffer with any of the following:

IBS (stomach discomfort / lack of control with pooing)

Migraines

Headaches

Skin conditions (Eczema, Psoriasis etc)

Rechecking things (eg. door locked, oven turned off)

Biting your nails

Drinking too much

Smoking

Irrational fears (snakes, spiders, heights etc)

Have you ever had a panic attack? (fast heartbeat, hot/cold flushes, fast breathing?)

Difficulty getting to sleep

Waking up during the night

Waking up too early

Difficulty waking up

Symptoms of Psychosis or Schizophrenia (hallucinations / delusions / other significant)

Any medication you are currently taking and what for (dose not required):

Any other medical conditions / comments / etc which may be helpful or relevant to mention? (There might not be!)

I understand that effort is required to make progress, and confirm that the information provided above is accurate and complete to the best of my knowledge

Phone: 07537143452

Email: rsmidohypno@gmail.com

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