Weir Mind — Client Agreement

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Hypnotherapy for Anxiety, Panic & Phobias

Client Agreement

SECTION 1 – Personal Information

Full Name *

Date of Birth *

SECTION 2 – Your Agreement & Session Detail

Client Agreement * Add photos, PDFs or documents

Privacy Agreement * Add photos, PDFs or documents

SECTION 3: Your Session Details

In person: treatment room, Stockton-on-Tees (TS18), full address sent separately

online: secure CliniForm link

Treatment Room Sessions are £100 for up to 60 minutes

Online Sessions are £90

My first session is on x at x

I understand my booking is not confirmed until payment has been received

SECTION 4: Your consent

I have read and understood the Client Agreement.

I have read the Privacy Notice.

I have told Kimberley about any health conditions and medication.

I understand hypnotherapy is a complementary therapy and does not replace my GP or NHS care.

I consent to hypnotherapy with Weir Mind.

I agree to my data being stored as described in the Privacy Notice.

I understand the fees, payment terms, 48-hour cancellation policy and 14-day cooling-off period.

AI note-taking. *

Yes, I agree to AI note-taking No, please take notes by hand

GP contact. *

Yes, Kimberley may contact my GP if needed No, I do not give permission

I hereby declare that the details are true and correct to the best of my knowledge and I undertake to inform you of any changes immediately. I have read and acknowledged the Privacy/GDPR policy. Thank you kindly for visiting us today and completing this form. Hope to see you again soon.

✍️

Client Signature *

Please sign below.

Please provide your signature

Date *

Age Restriction

We can only offer treatments to people aged 16 and over.

Additional Information

Thank you for sharing, I will be in touch soon

Secure Form from CliniForm

TS18

Tel: 07714164676 · kimberley@weirmind.co.uk · https://linktr.ee/WeirMind

Facebook: https://www.facebook.com/people/Weir-Mind/61555667935260/