Hypnotherapy Regression Consent Form

    Please complete the pre-assessment intake consent form below. Please fill in as much detail as you can – If you are uncomfortable with any of these questions, feel free to skip them however the more detail you are able to give me about yourself the more I can help you.

    Are you currently experiencing any of the following? (Please check all that apply)

    Nervousness / Anxiety Nightmares Compulsive tendencies Alcohol abuse
    Inability to relax Sexual dysfunction Teeth grinding Drug abuse
    Sleeplessness Poor health Compulsive Overeating Cigarette smoking
    Depression Self-mutilation Serious eating disorder PTSD
    Co-dependency Marital problems Lack of energy Abusive home situation
    Inability to focus attention Recent divorce Low self-esteem Abusive work situation
    Poor memory Illness/death of loved one Childhood trauma Lack of success
    War trauma Bullying Any other experiences

    Statement of Consent

    I work to international standards set through voluntary regulation in the profession itself and not by any country or state licencing requirements. I can offer to give you my best professional service to assist you on this journey, but you are responsible for your own healing and guaranteed success. Hypnotherapy acts as a complimentary therapy, not an alternative, to or replacement to professional health care and advice should be sought from your GP or other healthcare provider.

    We may contact you from time to time with information that may be relevant you.


    Please Note: You can unsubscribe from receiving contact from us at ANY TIME by contacting us – info@tranquil-retreats.com or 07984 665 331. For any information about our GDPR compliance policy please contact us.