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Patient Declaration - Clinical Hypnotherapy

All clinical hypnotherapy patients will receive this declaration before their treatment begins. Patients will be required to sign this form in order to commence therapy, but will have the opportunity to discuss any of the declarations listed. Any person under the age of 18 wishing to receive therapy will require a parent/guardian to co-sign this declaration.

Please read carefully:

I understand the nature of the therapy and it has been explained to my satisfaction.

I understand the probable duration of the therapy, or the estimate of the number of therapy sessions required for treatment. This has been explained to my satisfaction.

I have agreed upon a specific outcome for therapy.

I understand that a guarantee of a successful outcome is not possible, and accept that even though the therapist carries out this treatment flawlessly, the specific result may not be achieved due to circumstances outside of the therapist’s control.

I understand that there is a fee for treatment and agree to pay this in the manner agreed.

I understand that there is a 24-hour cancellation policy. All cancelled appointments after this time will incur a 50% cancellation fee, with the exception of illness or personal emergency.

I have disclosed all information which might affect the outcome of treatment or my well-being, and confirm that I have not received a diagnosis of psychosis or Borderline Personality Disorder.

I understand the therapist is not responsible for any recurrence of physical or mental problems prior to the present treatment.

I understand that treatment for severe medical conditions will only be undertaken after a medical/GP referral. I understand that GP consent is required prior to treatment for symptoms associated with severe medical conditions.

I understand that the therapist has the right to terminate therapy at any point they deem necessary.

I understand that any verbal or physical abuse towards the therapist will result in immediate termination of the therapy.

I understand that all information shared with the therapist is confidential and will only be shared with other healthcare professionals such as GPs and Clinical Supervisors if necessary. The therapist will inform me if this is necessary and ask me for my consent.

I understand that all trance work will be recorded with an audio device for the purpose of documenting the therapy and providing information if a referral is necessary.


I understand that my personal data will be collected for treatment purposes only and that this information is stored in accordance with the General Data Practice Regulations (GDPR). For more information on GDPR please visit

I understand that my therapy case file will be stored for 8 years after treatment has terminated in accordance with CNHC policy. 


Appointments cannot be offered to or conducted for any persons who have recently tested positive for Covid-19. Please consider self-isolating until a Lateral Flow or PCR test has indicated that you no longer have the virus.


Any persons who suspect that they may have Covid-19 symptoms must reschedule their appointment free of charge until a Lateral Flow or PCR test has indicated that they do not have the virus. 


  • I confirm that I have read and understood the above and will adhere to all Covid-19 requirements.

  • I confirm that to the best of my knowledge I do not currently have Covid-19 or Covid-19 symptoms.

  • I confirm that I will immediately inform the therapist should I develop any Covid-19 symptoms or test positive for the virus.


 I give my consent to the treatment by the therapist.

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