Change Easily by Carlotta Bernardo

    CONFIDENTIAL CLIENT QUESTIONNAIRE

    Note: All information will be kept strictly confidential except that which I am legally obliged to report, such as a threat of injury to yourself or others.

    Appointment Date

    Gender


    Do you currently have any physical/medical condition?

    If so, what?

    Doctor's Name and mobile number

    Are you currently taking any medication?

    If so, what?

    Reason for medication

    Have you ever been treated for an emotional problem?

    If yes, are you currently receiving treatment or counselling?

    Have you ever been treated for:

    Reason for coming to therapy:

    Have you ever had hypnotherapy before?

    If so, when?

    Do you have any intense fears? (ie. heights, stairs, lifts, tunnels)

    How did you find out about me? (Fb, Google, friend etc)


    Tick any items that indicate a problem to you:


    What are your two GOALS with regard to our sessions?

    RELEASE STATEMENT

    I hereby authorize Carlotta Bernardo to help me overcome my current situation utilising hypnosis techniques. I understand that hypnosis is not a medical procedure, and the results of hypnosis sessions depend on my own serious participation. Carlotta Bernardo cannot offer any guarantee of the success of my treatment. I am aware however, she will do everything reasonable in her ability to ensure my success. I confirm that the information disclosed is correct and complete to the best of my knowledge and belief.

    NOTE

    Before submitting the questionnaire, remember to sign below with your mouse (or finger if on a tablet or smartphone) and enter the date to validate the data entered.

    Signature:

    Date: