Strictly private & confidential

Client Confidential Record

Thank you for choosing @ Impactful Therapy. Please complete this form before your first session. It takes about five minutes.

1 Your details

Full name

Address

Address (continued) optional

Post code

Home / mobile telephone

Age

Date of birth

2 Your goals

What you want to achieve with hypnotherapy

Where did you hear about us? optional

3 Feedback & marketing

Are you happy for your feedback to be included in our marketing?

Yes No

4 Your agreement

I understand that the key to success is me and agree to make changes to achieve my goal. I am also aware that hypnotherapy cannot make me do anything I do not wish to do, and I appreciate my part in the process and will play the recordings to reinforce the therapy.

Signed type your full name

Date

09/11/2026

Your information is treated in the strictest confidence, held securely and used only to provide your therapy. It will never be shared without your consent, except where required by law.