lucid mind hypnotherapy

Client Intake and Agreement Form

Please complete this form before your session. All information is treated confidentially.

Name
Please indicate whether you have been diagnosed with, or currently experience, any of the following.
Please note that the presence of any of the above medical conditions may limit Giorgia Bettili's ability to offer hypnotherapy sessions.
Are you currently under the care of a GP/doctor for mental health?
If yes, please provide details below.
Please provide details if applicable.
My Health & Fitness to Attend
– I am not physically or psychologically unfit to attend a hypnotherapy session.
– I do not suffer from any undisclosed psychotic disorder.
– I will attend each session with full capacity, under no recent use of alcohol or recreational drugs.
– I understand that if Giorgia Bettili suspects recent alcohol or drug use, she may decline to proceed with the session.
Privacy Notice, Data Consent & Confidentiality
Your personal and health data is collected solely to prepare for and conduct your hypnotherapy sessions. It is stored securely and will never be sold or shared with third parties without your explicit consent.

Under UK GDPR, you have the right to:
– Access the personal data held about you
– Request corrections or updates
– Request deletion of your data at any time
– Lodge a complaint with the ICO (ico.org.uk)
Records are retained for 7 years in line with professional practice standards, then securely deleted. For the full Privacy Policy, please contact Giorgia Bettili directly.

– All content discussed in sessions will be kept strictly confidential by Giorgia Bettili.
– Confidentiality may only be broken in the following circumstances:
(i) with my explicit written permission;
(ii) in cases of child abuse or safeguarding concerns;
(iii) where there is imminent risk of harm to myself or others;
(iv) if records are subpoenaed by a court of law.
– If my case is discussed with a professional consultant for supervision purposes, I will never be identified by name.


Client Agreement
– Hypnotherapy is not a replacement for medical, psychological, psychiatric or counselling services.
– Giorgia Bettili does not treat, diagnose, or prescribe for any medical or psychological condition.
– Results from hypnotherapy vary on a case-by-case basis and cannot be guaranteed.
– I am free to terminate any session at any time, in observance of the cancellation policy.
– Full payment is required upon booking, prior to the session.
– A 48-hour cancellation policy applies. Cancellations made within 48 hours of the scheduled session will be charged in full.

Stay in touch (optional)
Declaration & Signature
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