E-mail:
Name:
Surname:

Age:

Current Occupation (job position) :

Do you enjoy your work? :

Please tick the appropriate boxes, providing further details where necessary.
Are you currently experiencing any of the following conditions?

Heart problems: NoYes
Do suffer from IBS or any other gastrointestinal issues?:
Migraine or epilepsy: NoYes
Have you ever been diagnosed with any psychosis (bipolar, schizophrenia, etc) ?: NoYes
Physical pain or injury: NoYes
Do you suffer or have difficulty with tension in any particular part of the body? :

Do you have any other specific health problems I need to take care of? (physical or mental):

List any medications you are currently taking, the dosage, and side effects for you.

Please list any fears, phobias, or compulsive tendencies:

Please list any other conditions occurring in your life that you believe are negatively affecting you in any way, or provide details of your concerns, needs, or fears :

How would you like Limitless program to help you?:

Sometimes we have a few problems to resolve. If you could narrow it down, which are the most important to work with in this program and why? :

Now, imagine yourself without these problems. How would your life be different? :

What are your two most important lifetime goals?:

What is your greatest dream for yourself? ?:

From the list check issues you perceive in your life: AddictionsDrinkingSmokingDrugsGamblingCompulsive bahaviourAnxietyStressFearsPhobiasPanic AttacsGuiltRelaxationEating problemsFood/DietAnorexiaBulimiaDepressionConfidenceSelf EsteemMotivationAchieving GoalsProcrastinationCareer IssuesInterview SkillsPublic SpeakingConcentrationExamsMemoryDriving SkillsSexual ProblemsFertilityIVFPregnancyBirthPain ControlHearingMobilitySkin ProblemsHair GrowthRelationshipsChildhood ProblemsSleep problemsOthers

DECLARATION
The information given above and throughout this consultation is, to the best of my knowledge, full and correct.

CONFIDENTIALITY
All information, whether verbal or written in notes, is treated as strictly private and confidential.

The therapist has a responsibility both to the client and to the community at large. Some moral and legal limitations, therefore, apply to confidentiality. These limitations mainly concern the risk of serious self-harm, harm to others, and child protection issues. If a situation arises in which the moral or legal limits of confidentiality are exceeded, the reasons will be explained by the therapist and discussed with the client at the time.

PROFESSIONAL REGISTRATION
The therapist carries full professional indemnity and public liability insurance and is registered with the following professional organizations:

The General Hypnotherapy Register (GHR).