Confirmation | ISHypno

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Trauma Clinic Online

In association with Inspired Solutions Hypnotherapy

Confirming your details

Please complete the following to confirm your details, we will then reply as soon as possible to confirm your eligibility & payment details:

Confirmation form

First name

Email

Last name

Phone

Date of Birth

Your current address

Doctor's name (if known)

Occupation

Address of your Doctor's Practice

Have you ever suffered with Psychosis or Schizophrenia (hallucinations, delusions or any other significant symptoms)? *

No

Yes

If yes, are you currently managing it with medication via your GP?

No

Yes

Any other details that might be relevant or helpful to mention? (optional)

1. I will ask Trauma Clinic Online if I have any questions

2. I will notify Trauma Clinic Online immediately if there is any significant change to my medical circumstances, and await their re-confirmation of my suitability for Rewind Therapy before proceeding

3. I will not use Rewind Therapy while under the influence of alcohol, drugs, or any other substance that can significantly affect my state of mind or body

4. I understand Rewind Therapy is not suitable for everyone, and under some circumstances can be harmful

5. I will not share the Online Rewind Therapy session with any other person(s) without written consent from Trauma Clinic Online, or record or reproduce the Rewind session in any form under any circumstances, and understand that I could face legal consequences for doing so & would be solely liable for any harm caused as a result of my actions

I declare that all the information provided here is accurate & complete

Your initials

Phone: 07537143452

Email: rsmidohypno@gmail.com

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