Registration-form – Equestrian hypnosis

Equestrian hypnosis

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About
Contact
- Booking Form
- Registration-form
FAQ Equestrian
Why do I use hypnosis in my psychotherapy practice?
“In the Zone” recordings
Site shop
Free stuff
Fees
News
Workshops

I also offer online therapy

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Home » Registration-form

Registration-form

Please complete below the Client Registration form in the strictest confidence , if however you would prefer to email me a pdf from then please follow this link to download the form separately. Client registration equestrian

Please also take a moment to read and accept my Terms and conditions

Name

Address

Mobile

Email

Relationship status

Single Divorced Separated Married Civil partnership

DOB

Children (if Yest click)

Occupation

Employer

Self - employed

Self employed

Do you take and Exercise Y/N

GP Name and Surgery Address

How did you hear about me ?

Google Search engine other Social media Recommendation Friend Family Word of Mouth

Do you have any current medical conditions?

Have you had treatments from a Psychiatrist, psychologist, therapist or counsellor?

Psychiatrist Psychologist Therapist Counsellor

If you clicked any of the above please state when and what for?

Any other medical information I should be aware of?

Are you taking any Medication or Drugs?

Yes No

If yes please state

Briefly - What is the reason for your consultation?

How long have you had this problem/issue?

Weeks Months Years

how does this disrupt your enjoyment of your riding?

1 2 3 4 5 6 7 8 9 10

how does this impact other areas of your life?

1 2 3 4 5 6 7 8 9 10

How does the problem affect you? (Physcially)

Emotional symptoms

Please complete the Tick box below.

1) Any insecurities 2) Low self esteem 3) Disturbed sleep or insomnia 4) Mood swings 5) Depression 6) Anxiety 7) Lack of concentration 8) Stress 9) Tension headaches

Horse name

Horse age

Horse breed

Has this horse contributed to your current problem and how?

Is this horse still contributing to your current issue?

Is there another horse / horses that contributed to this problem?

What have you tried so far to try and make this feeling go away?

Who is your Instructor/Trainer?

How long have you been working with them?

Do you compete – if so what discipline & level?

What level are you working at home?

Do you have any other worries/problems/stress going on in your life right now?

If you ticked any box please give it a score out of 1-5. E.g. the symptom/s being at best –1 and at worst –5.

If you ticked any box please give it a score out of 1-5. E.g. the symptom/s being at best –1 and at worst –5.

What are you hoping to achieve from receiving therapy?

How would you like to conduct your session? Please select from drop down list

Details of person to contact in case of emergency - (only needed if you are visiting my practice)

Yes accept to sending this information to me

Please note this form is not stored on the internet its is sent direct to my email only!

Yes you accept my T & C's

These can be viewed and download at the top of the page.

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