2026 Forms

Hypnotherapy Client / Patient Consultation & Information Collection Form combined with a Informed Consent.

Practitioner: Gerald Crawford
Profession: Hypnotherapist
Practice Location: South Africa

1. Client Personal Information

Today’s Date: ____ / ____ / ________

Full Name: ________________________________________________

ID / Passport Number: _____________________________________

Date of Birth: ____ / ____ / ________ Age: ___________

Gender: ☐ Male ☐ Female ☐ Other: __________________________

Marital Status: ☐ Single ☐ Married ☐ Divorced ☐ Widowed ☐ Partnered

Occupation: _______________________________________________

Employer (if applicable): __________________________________

2. Contact Details

Physical Address: __________________________________________

Postal Code: ___________________

Mobile Number: ____________________________________________

Email Address: ____________________________________________

Preferred Method of Contact: ☐ Phone ☐ WhatsApp ☐ Email

3. Emergency Contact

Name: _____________________________________________________

Relationship: _____________________________________________

Contact Number: ___________________________________________

4. Reason for Consultation (Tick all that apply)

☐ Anxiety / Stress
☐ Depression / Low Mood
☐ Trauma / PTSD
☐ Relationship Difficulties
☐ Grief / Loss
☐ Self-Esteem / Confidence
☐ Habits (e.g. smoking, nail-biting)
☐ Addictive Behaviours
☐ Weight / Eating Issues
☐ Sleep Problems / Insomnia
☐ Chronic Pain / Psychosomatic Symptoms
☐ Phobias / Fears
☐ Spiritual / Existential Concerns
☐ Personal Development / Performance
☐ Other (please specify): ____________________________________

5. Presenting Issue (Brief Description)

Please describe the main concern that brings you to hypnotherapy:

6. Medical & Mental Health History

Have you ever been diagnosed with any of the following?

☐ Anxiety Disorder
☐ Depression
☐ Bipolar Disorder
☐ Schizophrenia / Psychosis
☐ Epilepsy / Seizures
☐ Heart Condition
☐ Diabetes
☐ Chronic Illness
☐ None of the above

If yes, please provide details:

7. Medication & Substance Use

Are you currently taking any medication? ☐ Yes ☐ No

If yes, please list (including psychiatric medication):

Alcohol Use: ☐ None ☐ Occasional ☐ Moderate ☐ Heavy

Recreational Drug Use: ☐ None ☐ Past ☐ Current

Details (if applicable): ______________________________________

8. Previous Therapy or Hypnotherapy

Have you received therapy or counselling before? ☐ Yes ☐ No

Have you experienced hypnotherapy before? ☐ Yes ☐ No

If yes, please describe your experience:

9. Trauma & Safety Screening

☐ I have experienced trauma that may be relevant to this work

☐ I have had thoughts of self-harm in the past

☐ I am currently experiencing suicidal thoughts

☐ None of the above

If you have selected any of the above, this will be discussed sensitively and professionally.

10. Suitability & Contraindications (Tick all that apply)

☐ I understand that hypnotherapy is not a substitute for medical care

☐ I am not under the influence of drugs or alcohol during sessions

☐ I do not suffer from active psychosis unless cleared by a medical professional

11. Informed Consent

Please tick each box to confirm understanding:

☐ I understand hypnotherapy and the nature of the process

☐ I understand that results cannot be guaranteed

☐ I understand I may stop a session at any time

☐ I consent to participate voluntarily in hypnotherapy

☐ I understand confidentiality and its legal limits (risk of harm, legal obligation)

12. Confidentiality & POPIA Compliance (South Africa)

☐ I consent to the collection, storage, and protection of my personal information in accordance with the Protection of Personal Information Act (POPIA)

☐ I understand my information will not be shared without my written consent, except where legally required

13. Session Logistics

Preferred Session Type: ☐ In-person ☐ Online

Availability: ☐ Weekdays ☐ Evenings ☐ Weekends

Payment Method: ☐ Cash ☐ EFT ☐ Other: ________________

14. Client Declaration

I confirm that the information provided above is true and accurate to the best of my knowledge.

Client Name: ______________________________________________

Signature: ________________________________________________

Date: ____ / ____ / ________

15. Practitioner Notes (For Office Use Only)

Practitioner Signature: ____________________________________