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Intake & Consent

Please be advised that when partaking in hypnosis, it is necessary to have a place where you can rest your head. You are welcome to lie down if you wish.

I recommend you are able to rest your head back on a pillow against a sofa, armchair or bed head.

Birthday
Day
Month
Year
Multi-line address
Are you a student?
Yes
No
Are you employed or working outside of home?
Yes
No
Are you in a romantic relationship?
Yes
No
Do you have children?
Yes
No
How would you describe your overall health?
Excellent
Average
Needing Improvement
How would you describe your sleep?
Excellent
Average
Needing Improvement
A struggle
Do you take prescribed meditation?
Yes
No
Have you ever been given a mental health diagnosis?
Yes
No

Disclaimer.

Please know that I, Emelia Armstrong-Crews - Hypnotherapist and Counsellor, am not qualified and so not able to work with all presenting issues.

If I feel you cannot benefit from sessions with me, I may refer to your GP so you may receive the appropriate health advice.




Confidentiality.


I understand that all information shared is confidential and no information will be released without my written authorisation.


I further understand that there are specific exceptions to this confidentiality-


A. When there is risk of imminent danger to myself or to another person.


B. When there is a reasonable suspicion that a child or elder or any vulnerable person is being abused or neglected or is at risk of abuse.


C. By court order.


D. When therapist undergoes Clinical Supervision. In line with legal and ethical obligations, client anonymity will remain protected throughout.

Hypnotherapy with Emelia
Hypnotherapy

©2025 Hypnotherapy with Emelia

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