Client Case History
This form is designed to gather some background information about why you are seeking hypnotherapy. It is
conﬁdential* and will be used to plan the most eﬀective therapy approach for you. Please complete this form as
fully as possible and bring it with you to your initial consultation. Please continue on separate sheets as necessary.
YOUR CONTACT DETAILS
Name:
Telephone:
Mobile:
Email:
Address:
ABOUT YOU
Date of Birth:
Current Age:
Female
Male
Have you ever been diagnosed with or treated for clinical depression?
Yes
No
Have you ever been diagnosed with or treated for epilepsy?
Yes
No
Occupation:
ABOUT YOUR HEALTH
Details of any medication you are taking (including over the counter medications):
e: [email protected] | www.vickicrane.co.uk
Name and address of your GP:
WHY ARE YOU SEEKING HYPNOTHERAPY?
Please give a brief description of the problem(s) that you are seeking hypnotherapy for:
Client Case History (Continued)
BACKGROUND HISTORY & INFORMATION
How long have you had the problem(s)?
When did the problem(s) first start?
Have you previously tried any other medical or therapeutic approaches (including hypnotherapy) in relation to this particular problem?
Please describe what you wish to achieve from hypnotherapy:
Have you experienced hypnotherapy before for any other problem? If so, please give details:
Please include any other information that you feel may be relevant here:
OFFICE / THERAPIST USE ONLY:
Initial Deposit (£25) paid online:
Yes
No
Initial Deposit refunded at final session:
Yes
No
Reason:
Number of sessions:
*The contents of this form, any notes, recordings and anything that is discussed during hypnotherapy sessions will be treated in the strictest conﬁdence with the following exceptions: 1) Where you
give written consent for conﬁdentiality to be broken. 2) Where the therapist is compelled by a court of law. 3) Where the information is of a nature that conﬁdentiality cannot be maintained, for
example: The possibility of harm to yourself or others exists; In cases of fraud or crime; When minors (under 18 years old) are involved. 4) During supervision: Where details of case histories are discussed,
your identity will not be disclosed, except in the circumstances described above. 5) Where a referring GP or other healthcare professional requires a report. A copy of the report will be available on
request. For further information, please refer to the Client Contract.