Debbie Waller Hypnotherapy

& Yorkshire Stress Management

2A Assembly St, Normanton, WF6 2DB

This form collects personal data (information) to help me to prepare for your therapy session. It will also collect payment for your first session, or a block of sessions, or you can request an invoice so you can make a bank transfer.

The form has five pages, but many answers are simply a case of reading the question and ticking yes or no, so please bear with me and work your way steadlily through. The CNHC (with whom I am registered) asks that whilst COIVD is an issue we keep face to face time to essentials, and collecting information from you here instead of in session helps to do that.

If you are not able to complete the form online please contact me. I can send you a printed version to return to me by post at no further charge. Or I can arrange to interview you on the phone or by Zoom to complete the form for you, but a nominal charge will apply to cover my time. 

The form and payment should reach me before 6pm on the day before your appointment. If it does not do so, your appointment may not be able to go ahead.

If you have any problems completing it please contact me on 01977 678593. 

GDPR

Please read https://www.debbiewaller.com/confidentiality-policy before submitting this form. This tells you how I collect, look after and use your personal data. Under the GDPR, (Data Protection law) I need you to agree to each separate use of your data by ticking all available options. You can withdraw consent at any time by letting me know in writing.

About you

Your Health

Sometimes health issues can affect which approach is likely to be the most effective for you.

Your Lifestyle

Knowing about your lifestyle helps me to understand the pressures you are under and where your support comes from. This helps me to understand how the issues we are looking at might fit in with other things in your life. It also helps me to choose the techniques and approaches that will be of most help to you.

How can I help?

This part is about what you want me to help you with.
You only need to be brief, we'll talk about this in a lot more detail when we meet.

Nearly there now ...

Terms & Conditions 

Please read through these and indicate your acceptance at the bottom.

All clients

a.       You agree to being hypnotised for therapeutic reasons. The price you pay today will not increase, unless there is a break of more than four months between appointments.

b.      You accept that treatment is offered on the basis of the information you supply, and affirm that this has been complete and truthful.

c.       You accept that while I will always do my best to help you achieve a successful outcome to your therapy, no guarantees can be offered.

d.      Non attendance: appointments can be cancelled or rescheduled, and 24 hours’ notice is required. If you fail to attend without notice you will be liable to pay 50% of the cost of the session.

e.       The late notice penalty will be waived if the reason for your non-attendance is that you develop COVID symptoms, are diagnosed with COVID or go into self-isolation.

f.        You are free to end or withdraw from therapy at any time. Sessions paid for in advance but not used will be refunded on request, subject to item (d). Refunds will reflect the actual price paid.

g.      If you arrive more than 5 minutes late you will have to shorten or re-schedule your appointment.

h.      Anti-social behaviour will cause the immediate cessation of treatment.

i.        The information you give me will be kept confidential unless one of the following applies:
- there is a legal requirement for me to share information e.g. where the Children’s Act applies or a court order is issued
- there is good cause to believe that not to disclose information would expose you or others to a serious risk of harm
- I have to share your contact details for Track and Trace purposes

j.        If you have been referred to me by your employer or GP, or if I am working with you as part of a care team, I will share prearranged levels of information with the others involved.

k.      I occasionally share anonymous case histories with other hypnotherapists or in hypnotherapy publications for the purposes of supervision or training. Anonymous means your personal details are removed and no information that might identify you is used.
If you do not wish your information to be used in this way, please let me know.

l.        If you have any questions or complaints about your therapy, you agree to talk to me about them first. If we can’t resolve the situation satisfactorily you then have access to the formal complaints procedure of the General Hypnotherapy Register, 01590-683770.

m.    Debbie Waller Hypnotherapy is a trading name of Yorkshire Therapies & Training Ltd.
Registered in England and Wales No. 10275858, Registered Office: Keldale House, Beal Lane, Beal, N Yorks, DN14 0SQ

Online working

n.      If we are working online, you accept that levels of confidentiality may be affected by factors that are beyond my control, for example, the actions or failures of the platform provider (e.g. Zoom).

o.      If we are working online, you accept that it is your responsibility to ensure that you are not interrupted or overheard by others at your end of the connection.

p.      If we are working online you agree that we are working under the jurisdiction of the laws and regulations in force in the United Kingdom.