Confidential Consultation Form - Mind Matters Hypnotherapy

Hope Wesley | Hypnotherapist Perth | Australia

Call Hope: 0430 224 130

WEBSITE MENUCLOSE MENU

Home
About Hope
How Can I Help You?
Contact Hope

When you click on the submit button the page will redirect and you will receive an email to say the form has been received, if either of these do not happen it is possible fields have filled missed, please take a moment to check the form.

I have confidently displayed the Secure site logo for some years now, however sadly I think we are all becoming aware that we cannot guarantee digital information to be 100% secure.

For this reason, I have changed most the fields in my consultation form so that you can choose what information you share.
Please be aware that if you do intend to claim through your health fund all contact details will be required.

I look forward to meeting you soon.

Hope

Secure Website

Thank you for filling out my consultation form

* indicates required field

Name:*

Date of birth/ age:

Address:

Suburb:*

Consultation date:*

Email:*

Occupation:

Phone:*

Relationship status:

Relationship issues:

How did you hear about Hope?:*

Have you ever been diagnosed with:*

None
Epliepsy
M.P.D. (Multiple personality disorder)
Schizophrenia
Bipolar
Psychosis
Depression

Any phobias/ fears/ specific anxieties:*

YES
NO

Details of any phobias/ fears/ specific anxieties:

Concise statement of the issue/problem: What do you want to change?*

What is your goal/Preferred response/How do you want to be instead?*

Have you been this way before (Goal/Preferred)?*

When have you been this way (Goal/Preferred)?

Are there any situations where this is not an issue?*

What would you change yourself to reach the goal?*

Payment: I choose to pay by*

PayID: 0430224130
Paypal: https://www.paypal.com/paypalme/HopeW

***Please read to the bottom of the page before submitting this form***

I understand and accept Mind Matters Hypnotherapy cancellation policy.*

YES
NO

If you are still on this page after you submit the form please check for errors.

You will receive an email and be transferred to another page when form has been submitted.

Thanks

Hope

CAPTCHA Code:*

Your Zoom link will be forwarded to you shortly.

Package
Initial session (2 – 2½ hours)
Further sessions

Individual sessions $225 Per hour $225 Per hour

Sessions plan $350 $200

Quit smoking $400

.

Please note: Cancellations of appointments should be made no less than 48 hours prior to appointment to avoid cancellation fee.

Contact Hope

Mind Matters Hypnotherapy is conveniently located at
123 Aberdeen Street, Northbridge, Perth WA.
To see how hypnosis can help you call Hope today

Call Hope: 0430 224 130

Privacy Policy

Disclaimer

Hypnotherapy Blog

Copyright © 2018 Mind Matters Hypnotherapy | Perth | Designed by Hostcat