Stop smoking hypnotherapyregistration form

Please complete this form before your session. Your answers are confidential and help me prepare for your session.

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About you

First name

Last name

Date of birth

GenderOptional

Phone number

Is it OK to leave a message on this number?

YesNo

Address

Address line 1

Address line 2Optional

Town or city

CountyOptional

Postcode

Country

Your smoking or vaping

How did you hear about me?

What do you smoke or vape?

How much do you smoke or vape a day?

When did you start smoking?

Have you stopped before?

If so, how long for, and what method did you use?

What do you associate with smoking?

Why do you want to stop?

Have you had hypnotherapy before?

Anxiety, depression, stress or other concerns

Are you currently struggling with anxiety, depression, stress or any other mental health concerns? These can affect smoking, so it helps me to know.

Before your session

Hypnotherapy is a tool for change, not a magic solution. It helps you reach your subconscious so that change can happen. I don’t fix the problem for you; the change comes from your own understanding and resources.
Everyone responds differently to hypnotherapy, so results can’t be guaranteed.
It’s a collaborative process. The outcome depends on your motivation and commitment.
Hypnotherapy is not a substitute for medical treatment, psychological or psychiatric care, or counselling.
I need 24 hours’ notice to cancel or rearrange an appointment. With less notice, the full fee is charged.

I have read the points above and the terms and conditions, and I accept them.If my session is less than 14 days after I book, I’d like it to go ahead. I understand that once it has taken place, I can no longer cancel it for a refund.I consent to Susannah Saunders keeping the information on this form, including information about my health, to prepare for and provide my session, as described in the privacy policy.

Type your full name as your signature