A Typical Contract

Paul Avard MA, Registered Hypnotherapist RH(CNHC)

Hypno-Therapy & Hypno-Psychotherapy

Client Contract (Adult / Child)

Full Name of Client: ……………………………………..             Date of Birth: ………………………..

Home Address: ………………………………………………………………………………………………….

Post Code: …………          

Phone No: Home: ………………    Mobile: …………………

Reason for seeking help at this time: ……………………………………………

GP Name:……………………………….       Surgery Phone No………………………….

I am currently seeing my GP and I am being treated for ………………………………………..

I am taking ………………………………….. (name of medication) as a treatment.

AND / OR I am seeing a counsellor / therapist for help with ………………………………………………

I give permission for Paul Avard to contact my GP or counsellor (or both, if necessary) to clarify whether hypno-psychotherapy or hypno-therapy is contra-indicated OR if there is something in my medical background which may cause complications should hypno-psychotherapy or hypno-therapy be undertaken.

I understand that any information will be treated with strictest confidentiality – subject to any limitations imposed by the law, and professional Code of Ethics, as explained by Paul Avard.

I agree to aspects of our meetings being shared with his supervisor during Paul Avard’s clinical supervision sessions.

I agree to the programme of treatment as outlined by Paul Avard

 
Signed: ……………………………………………..         Client Name: ………………………………………

 

Case Notes:

I am registered as a Data Controller with the data protection people and as such I keep your records electronically on an iMac desktop computer which is password protected and I promise and affirm that I will never pass your personal details to any third party, for any reason, whatsoever.