Peacock hypnotherapy Adult Initial Consultation Call now Initial Consultation How are we going to help you? *What would you like to achieve by coming here? *NameAgeStreet AddressHouse Name / NumberCityZIP / Postal CodePhoneEmail AddressI hereby consent to receive Solution Focused Hypnotherapy.YesNoOccupationWho 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 upAre you on any medication? *Any other info?Dr's Name and PracticeWhere did you hear about Peacock Hypnotherapy?Send Message a warm welcome Get 30 Minutes FREE Zoom session to find out more Click here to book your session