Hypnotherapy Appointment Request

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All information will remain confidential and will not be passed onto, or made available to, any third party.

Are you taking any prescribed medicine at the moment? YesNo

Have you been to see any other health care professional about this problem? YesNo

Have you ever been diagnosed as suffering from a mental illness? YesNo

We are committed to safeguarding the privacy of our website visitors and service users.
All information will remain confidential and will not be passed onto, or made available to, any third party.