2026 Forms

Online Group Session Information Collection Form and Informed Consent Form

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

1. Client Personal Information

Today’s Date: ____ / ____ / ________

Full Name: ________________________________________________

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

Gender: ☐ Male ☐ Female ☐ Other: __________________________

2. Contact Details

Physical Address: __________________________________________

Mobile Number: ____________________________________________

Email Address: ____________________________________________

3. 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:

4. Previous Therapy or Hypnotherapy

Have you experienced hypnotherapy before? ☐ Yes ☐ No

If yes, please describe your experience:

5. 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

6. 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)

7. 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

8. 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: ____________________________________