New Client Form

You can fill out the online form below or download this form, print it out and mail it to Lee Bannister.
Please fillout this form as best as you can, giving as much information as you can.
Name
Address
Email Address
Telephone Mobile
Next of Kin Relationship
Next of Kin Telephone Next of Kin Mobile
Please list any sporting or physical activities in which you are currently or have taken part in:
Are you currently takeing / recently taken any medication? Yes No
If yes, please give details:
Have you suffered from, or been treated for any of the following?
Heart Problems Veruca Schizophrenia
Athletes foot Pregnant Psychoses
Phlebities; Swelling / Pain Depression
High temperature / flu Diabetes Severe mental illness
Open wounds Thrombosis Sleepwalking
Varicose veins Chemotherapy Epilepsy
Disc / Back problems Contagious disease    
High blood pressure Undiagnosed lumps Do you use HARD drugs
Cancer Tendon rupture    
Have you had any major operations within the last 5 years? Yes No
If yes, please give details:
Do you have a criminal conviction? Yes No
Have you come because of a specific problem? What do you think it is?
What would you like to work on?
If there is anything else you would like to change about yourself, what is it?
What goals do you have?
What do you have to help you achieve these goals?
When will you know you have achieved your goal?
What experiences have you had that were similar?
What makes you really relaxed?
Why have you come to see me now?
Are you prepared now to make a decision to move towards your goals?
Do you see things in pictures or images?
Do you have any doubts or concerns?
What do you know about hypnotherapy? Have you been hypnotised before?
Are you ready to be completely relaxed? Are you ready to be hypnoised now and experience Complete Relaxation?