Contact and Referral

Having decided that Hypnotherapy is for you, and you wish to proceed further, then please complete the following Initial Application form and send this to me by clicking on the 'SEND' button at the bottom of the form. [Please note that all boxes must have some information, for the form to be successfully sent. If any section is not relevant just type in 'none' or 'N/A'. Thank you.]

If you would like to refer a child or young person, then please fill out the form as advised above, making sure to note the child/young person's name and age.

If you have any queries, then please do contact me either by phone on 07590047990, or email by clicking on email link below:

Contact via Email


Initial Application

(Please complete this application as fully as possible, but be aware that I may need additional information at our first contact/meeting)