LIFE CYCLE THERAPIES

Tracey Robins, Dip Hyp, Dip RTh, Ct LBL

www.lifecycletherapies.com
lifecycletherapies@hotmail.com
CONFIDENTIAL ENROLMENT
QUESTIONNAIRE
Note: All information will be kept strictly confidential except that which I am legally obliged to report, such as
a threat of injury to yourself or others. If you are uncomfortable in any way with any of these uestions, feel
free to skip them. !lease be aware that the more you can tell me about yourself, the more I may be of
assistance to you. "eel free to use more paper to go into detail about any issue you wish me to know about
you, or to help you with. !lease complete and sign the form and return it to me.
Name:
#ate of $irth:
Age:
Address:
!hone Numbers:
%obile:
&ork:
'ome
(mail:
!ersonal )tatus:
Name of )pouse * !artner:
Names + Ages of children:
,egression -herapy .uestionnaire
1
'ow do you like to relax/
0ist any fears of phobias.
#o you experience any compulsi1e tendencies/
'a1e you e1er needed to work with mental health professionals/ 2r taken anti depressants/ If yes
what where the details.
Is a doctor currently treating you/ If yes what are the details/
0ist any prescribed or non prescribed medications you are currently taking including alcohol, cigarettes
etc and the side effects.
&hat is your current occupation/
#o you enjoy your work/
!lease list any traumatic life e1ents.
&hy are you seeking a !ast 0ife ,egression )ession/ !lease be as specific as you can.
&hat pre1ious experiences of ,egression do you ha1e/
&hat is the emotional and psychological health of your parents/
,egression -herapy .uestionnaire
2
#o you follow any )piritual * ,eligious practices or meditation/
0ist any other conditions occurring in your life that you belie1e are negati1ely affecting you in any way.
RELEASE STATEMENT
I hereby a!hori"e Tracey Robins to help to ,egress me for the purposes outlined in this intake form, and
for future purposes that I may reuest. I understand that ,egression -herapy is not a medical procedure and
that no medical benefits are being offered to me. I understand that the success of my ,egression -herapy
depends on my ability to relax and my desire to create change in myself. I understand that, because the
results of hypnosis sessions depend on my own serious participation, -racey ,obins cannot offer any
guarantee of the success of my treatment. I am aware, howe1er, that she will do e1erything reasonable in
her ability to ensure my success.
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P#ease No!e: I can often re4arrange appointments if necessary but if you need to rearrange or cancel with
less than 56 hours notice, I will need to charge you for your missed appointment.
,egression -herapy .uestionnaire
3