SPORT PERFORMANCE CONSULTATION FORM

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 questions, feel free to skip them. Please be aware that the more you can tell me about yourself, the more I may be of assistance to you. Please complete and sign the form and then press “SUBMIT”.

Name

First Name

Last Name

Date of Birth

Age

Mobile Number

How do you like to relax?

What is your favorite colour?

List any fears or phobias

Please list any particularly significant or traumatic life events that you feel have impacted your golf performance

Please list any other conditions occurring in your life that you believe are negatively affecting you in any way. Use as much space as you want to tell me the details of your concerns, needs or fears.

At this moment in time, why are you seeking help with Ryan Scott Performance ? Please be as specific as you can (curiosity is ok but curiosity about what?)

What previous experiences of Hypnotherapy, Regression and/or meditation do you have?

When you are playing/performing at your best, what is it you feel you are doing well?

Key words to describe what you are feeling when you are Performing well?

When you are under performing, what is it that you feel could be better?

Key words to describe what you are feeling when you are under performing?

Ultimately, what would you like to achieve from this session (or sessions)?

Is there anything else that you think I should know?

Release Statement (terms and conditions)

I hereby authorise Ryan Scott to help to Hypnotise me for the purposes outlined in this intake form, and for future purposes that I may request. I understand that Hypnotherapy Therapy is not a medical procedure and that no medical benefits are being offered to me. I understand that the success of my Hypnotherapy and Regression Therapy depends on my ability to relax and my desire to create change in myself. I understand that, because the results of the sessions depend on my own serious participation, Ryan Scott cannot offer any guarantee of the success of my treatment nor am I entitled to any refund of monies paid. I am aware, however, that he will do everything reasonable in his ability to ensure my success.

I understand Ryan operates a non refundable 48 hour cancellation policy and agree to this

I agree to the terms and conditions

I acknowledge and agree that my personal data will be recorded for treatment, accounts and communication purposes and this information is stored in accordance with the General Data Protection Regulations. I also acknowledge and agree that it will also be kept for six years in accordance with General Hypnotherapy Standards Council (GHSC) Code of Ethics, and that after that period, it will be destroyed.

Signature

Typing your signature is acceptable

Date