Peacock hypnotherapy

Adult Initial Consultation

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Initial Consultation

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What would you like to achieve by coming here? *

Name

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I hereby consent to receive Solution Focused Hypnotherapy.YesNo

Occupation

Who were you brought up by *

Position in family (older/younger siblings)

Married/Steady Relationship? (partners name if yes)

Do you have Children (please add names and ages if yes)

Tick the ones that apply - Do you suffer from:IBSMigraineRecheck thingsNail bitingDrink too muchSmokeIrrational fears of heightsIrrational fears of enclosed spacesIrrational fears of snakes, spidersEver had a panic attack?Difficulty in getting to sleepWake up during the nightWake up too earlyDifficulty waking up

Are you on any medication? *

Any other info?

Dr's Name and Practice

Where did you hear about Peacock Hypnotherapy?

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Get in touch

110 Clarendon Road, Hinckley, Leicestershire, LE10 0PL

T: 07544814694
E: info@peacockhypnotherapy.co.uk
Mon - Fri: 8.30am – 8.30pm

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Treatments

Stress & Anxiety
Confidence
Sleep
Grief
Depression
Phobias

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