Online Consent Form Name * First Name Last Name Address * Email * Phone * (###) ### #### Date of birth * MM DD YYYY Please provide a brief description of how I can help Please select any that are applicable to you Experience IBS Get Migranes Bite Nails Irrational Fears / Phobias Concerns about alcohol / drug use Sleep Issues? Trouble getting to sleep Wake up during the night Wake up too early Sluggish in the morning Have you read my GDPR notice? * View the GDPR Policy here. Yes No Doctors practice * Do I have permission to contact your GP? * Yes No I hereby consent to receive Solution Focused Hypnotherapy from Lorraine Sheppard * Yes Thank you!
