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Hypnotherapist, NLP and IEMT Practitioner

Client Intake Form

Please complete the following information before your first session.

Boxes with an asterisk must be completed by Guide Me Clients.

* First name

* Last name

Address

* Emergency contact

* Phone

GP Name and Surgery

* All Medical Conditions

* Any Formal Psychological Diagnosis

* Any Suspected, but Undiagnosed Conditions

What would you like me to know before our first session?

* Email

* Please print your name here to confirm that all the above info is correct

Yes, subscribe me to your emails. You can unsubscribe at any time.

Contact

Use this form to arrange a free chat or ask a question

Worldwide on Zoom or WhatsApp

Based in Hertford, Hertfordshire (room available in Bengeo)

I can also come to your home, if you are local to me.

Phone or text me on: 07527 577987

You can also message me via Facebook

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