New Client Form

Do you have any physical or psychological conditions or illnesses?
Have these conditions been medically diagnosed?
Have you had hypnotherapy before?
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I hereby authorise Laura Culley to use hypnosis with me for the purposes outlined on this form and for the future purposes that I may request. I understand that the success of my hypnosis therapy depends greatly on my own ability and desire to effect change in myself. I understand that the results of my sessions depend greatly on my own serious participation and that no guarantees are made as to the success of my treatment. I am aware, however, that Laura Culley will do everything in her power to ensure my success. I also understand that I have other choices from which to seek assistance regarding my specific concerns, and I have chosen hypnotherapy at this time. I have read Laura's Privacy Policy and am happy to agree to those terms. 

If you have not had therapy with Laura Culley Hypnotherapy before, please complete this form in as much detail as possible and return it to me by hitting the "Send Form" button at the bottom of the page. If completing it for your child, please use their details where appropriate. 

    122, High Street, Honiton, Devon EX14 1JP

    Hanover House, Chard Street, Axminster, Devon EX13 5DZ

    S&S Wellness and Beauty, Exminster, Devon  

    Call 07577 485250

     © Laura Culley Hypnotherapy 2019