121 Disclaimer Form | Fresh Focus Therapy

Your Details

First name

Last name

Phone

Birthday

Day

Month

Year

Address

GP Name & Address

How did you hear about us?

Occupation

Tell us about yourself:

In your own words, what has brought you to therapy?

Have you had hypnotherapy or other therapy before? (What type, when, what it was for, what you did or didn't like, what you learnt.)

We'll agree goals together in our first session, but briefly — what would you like to gain from these sessions?

Is there anything else you feel is relevant to share?

Health Assessment

Are you currently experiencing any of the following?

Heart Problems

Migraine or Epilepsy

Physical pain or injury

Any specific fears or phobias

Have you contacted your GP about the condition you are seeking therapy for?

Yes

A bit more about your health

Your Health

Have you ever been diagnosed with any psychological or psychiatric condition?

Do you have any other long term health problems?

Are you taking prescription mediation?

Do you suffer from IBS or any other gastro-intestinal issues?

Do you hold tension in any particular part of your body?

Add description to anything you ticked above.

Declaration & therapy agreement

Payment of fees — Sessions last approximately one hour. The hourly rate is £75 unless otherwise stated. Fees are payable at the beginning of each therapy session. Failure to pay may result in delay or cancellation of future sessions. Invoices will be sent and payment is requested via BACS.

Cancellation — We ask for 48 hours' notice for cancellation, otherwise you will still be charged.

Confidentiality — All information, whether verbal or written notes, will be treated as strictly private and confidential. The therapist has a responsibility to the client and the wider community, meaning some moral and legal limitations may apply. These limitations mainly concern the risk of the client harming themselves or those around them, or 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.

Insurance — The therapist carries Professional Liability, Malpractice and Personal Injury insurance with Balens Ltd.

Getting the most from your sessions — We advise you to switch off your phone and remove as many potential distractions as possible. Therapy is a collaborative process in which success is not guaranteed; progress depends in part on the motivation and participation of the client. Unless you request otherwise, a follow-up questionnaire may be sent after treatment concludes, and a request to leave a review on public or marketing platforms may be made — this is entirely optional.

Case studies & marketing — Unless you request otherwise, Fresh Focus Therapy holds the right to create an anonymised case study of your presenting situation, along with any testimonials offered. This is done confidentially — your name and personal information will never be shared.

Code of ethics & practice — I accept and follow the principles set out in the Code of Ethics and Conduct of the NCH (National Council for Hypnotherapy) and the Code of Ethics of the GHR (General Hypnotherapy Register).

Kerry Dawes, CBH Dip — Director & Hypnotherapist, Fresh Focus Therapy

I confirm that the information I've given is, to the best of my knowledge, full and correct, and I agree to the terms set out in the therapy contract above.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Date picker