Acupuncture & Health Consultation form - Patti Hemmings Therapy Harrogate

Name*
First Last
What name do you preferred to be called by?
Contact number*
Email*
Preferred Contact Method
Is It okay to leave messages?
- Yes
- No
Emergency contact person & their number*
GP Surgery Details*
Please note: I don’t routinely contact your GP.
Are You Taking Any Medication? If so, please state.*
The main reason you are seeking treatment. Please state.*
How does this health issue/problem affect you?*
Please Take 5 Minutes to Describe, In Your Own Words, the Issue That Brings You To Me Today and The Effect it Has On You.*
Any Other Issues You Want to Mention.*
Any Previous Experience of Therapy.*
Any Particular Likes or Dislikes.*
What Makes You Happy or helps you relax.*
Desire To Change: Where 1 = Not Bothered and 10 = Absolutely Must Change, On a Scale of 1 to 10, how would you related your desire to change?*
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10

General Hypnotherapy Register

The British Acupuncture Council

Federation of Holistic Therapists

Membership number: 207066.

Payments taken by Paypal/IZettle