ARK Hypnotherapy Rotherham

Client Intake Form

Please fill out and submit the form below.

If you are seeking out help for a chronic pain condition, please identify the nature of your condition and confirm that your condition has been diagnosed by a suitably qualified medical professional, such as your GP or surgeon.
A “contraindication”, in medical terms, refers to a symptom or condition which can make treatment risky. If you have been diagnosed with the any of the following conditions, hypnotherapy may not be an advisable treatment option for you. Having one of the following conditions does not necessarily rule out hypnosis, but it is important that I know about it in order to design your treatment plan appropriately. Please fill in the following form and return it to me so that we can discuss your treatment options.