Break Up With Stress

Suitability questionnaire

This form helps me prepare for working with you and check that hypnotherapy, and I, are the right fit for you. Most questions are a quick tick or yes/no.

Everything you share is kept confidential (see the privacy section at the end). If you'd rather not complete it online, please get in touch.

About you

First name

Family name

How would you like to be addressed? (name and pronouns)

Email

Best phone number to contact you

Is it OK to leave a message on that number?

Yes

No

Name and phone number of someone I could contact in an emergency

Which medical practice (GP) are you registered with?

How did you find out about my service?

Your health

Sometimes health issues affect our approach.

Have you previously received any psychological therapies (e.g. psychotherapy, counselling)?

Yes

No

Have you ever been diagnosed with any of the following? (Please tick all that apply)

Are you currently taking any prescription medication? If yes, please list the name and dosage. If not, write 'None'.

Have you ever had suicidal thoughts or tried to harm yourself? (This doesn't preclude you from hypnotherapy. I just need to know in terms of scripting and wording

Yes

No

How would you rate your current sleep?

Good

Variable

Poor

Have you discussed any of your worries or conditions with your GP? Please give details.

Have you previously received hypnotherapy?

Yes

No

What you'd like help with

Aside from stress and anxiety, please tick any of the following that apply to you

What are your symptoms, and how do they affect your life?

What are your goals for hypnotherapy?

If there's more than one thing, what's the most important?

Your stress

This is your space to tell me everything that's going on for you. Write as much or as little as you like.

When do you feel stress? At work, at home, or at other times? Please describe.

Tell me about your stress or anxiety, and how it affects your life.

What happens when you feel stress? Think about your thoughts, feelings, behaviours and any physical effects.

When did you first notice this, and do you know why it's happening?

What are your current coping mechanisms?

Do any of your family members experience stress or anxiety?

Have you tried any stress management or anxiety treatments in the past?

Why now? What's prompted you to seek help now?

If you don't get support now, what will happen?

Do you feel you have a good work/home balance?

Your lifestyle

Knowing about your lifestyle helps me understand the pressures you're under and where your support comes from.

Are you…

What is your occupation?

If this isn't your ideal job, what would your ideal job be?

Who lives in your household?

How high are your stress levels?

Low

Variable

High

How good is the support you get from family and friends?

Excellent

Good

Limited

Tell me about the support you get from family and friends.

Have there been any big changes in your life in the last 12–18 months (home, work, family)? Please give details.

Do you have any fears or phobias (other than what you're coming to see me for)?

Yes

No

How healthy is your diet?

Very healthy

Generally healthy

Could be better

Unhealthy

What is your smoking status?

Never smoked

Ex-smoker

Currently smoking

Vape

Have you ever taken recreational drugs?

Never

More than a year ago

Less than a year ago

Currently

How often do you drink alcohol?

What exercise do you do in an average week?

What is your idea of complete relaxation, and what do you do for fun or to relax?

What would you like to do but don't seem to have time for?

Terms & conditions

1. I am taking part in hypnosis by my own choice, because I want to be here.

2. I understand that I am not a patient, but a co-operator in my hypnosis experience.

3. I acknowledge the futility of blame, for myself and for others.

4. I understand that my progress involves how I care for myself physically, mentally, emotionally and spiritually.

5. I understand that transformation is a process and can take time.

6. I agree to being hypnotised for therapeutic reasons.

7. I accept that support is offered on the basis of the information I supply, and confirm it is complete and truthful.

8. I accept that while Lavinia will always do her best to help me achieve a successful outcome, no guarantees can be offered.

9. I am free to end or withdraw from the programme at any time.

10. Anti-social behaviour will cause the immediate end of sessions.

11. Information I give will be kept confidential unless there is a legal requirement to share it (e.g. where the Children Act applies or a court order is issued), or there is good cause to believe that not disclosing it would expose me or others to a serious risk of harm.

12. If I have been referred by my employer or GP, or Lavinia is working as part of a care team, pre-arranged levels of information will be shared with those involved.

13. Anonymous case histories may occasionally be shared with other hypnotherapists for supervision or training, with all identifying details removed. I can ask for my information not to be used in this way.

14. I understand that hypnotherapy is not a replacement for medical treatment, psychological or psychiatric services, or counselling.

15. I understand that the hypnotherapist does not treat, prescribe for or diagnose any condition.

Privacy and online working

Your personal and sensitive data is kept private, held securely and used only in the ways you agree to below. This covers session notes, messages and emails.

If we work online, confidentiality may be affected by factors outside my control, such as the platform provider (e.g. Zoom). It's your responsibility to make sure you aren't interrupted or overheard at your end. We work under the laws and regulations of the United Kingdom.

I agree to my personal data being used:

To deliver therapy

To communicate with me between sessions

To collect payment and keep records

I have read and accept these terms and conditions

Signed (type your full name)