Intake

Knot undone therapy|Intake

INTAKE FORM

Be excited. I would like to invite you to take a moment to check in with yourself and where you are. What is that you struggle with? In which areas of your life do you require help to be able to change? What is your priority?

By highlighting what is that you really want to achieve we can focus your session outcome on clearly instructing your mind on what is needed.

Complete the below and let’s get started.

    Name and surname
    Preferred name
    Date of birth
    Relationship status
    Address
    Email address
    Phone number
    Medical professional's OR next of kin name/contact number
    Please briefly describe your health problems (past and current)
    Are you currently taking any medication?
    If yes - what kind of medication?
    Have you ever been diagnosed with a mental health condition? (Please note that I will be unable to offer my professional services if you suffer from epilepsy or any form of psychosis)
    If yes, please briefly describe it
    Have you ever been hypnotised before?
    If yes, how was your experience?
    What is that you really want? Please describe briefly your ONE issue (e.g. to be free from phobia, smoking, headaches, insomnia, alcohol addiction; to be confident, to find love; to reduce your weight; to excel at your job, to improve your sport performance)
    If your issue is a physical illness or problem, please explain and list your symptoms and any relevant to that illness information.
    What is your desired outcome/ result of the session?
    Please select the areas that currently concern you
    How did you hear about Aleks/knot undone therapy?

    • All In-person booked sessions require a non-refundable € 100 deposit.
    • No refunds will be issued for cancellations within 48 hours of the session appointment
    • No deposit is required for online sessions, however payment for the online sessions must be made at least 24 hours before the scheduled session start time.
    • The cost of a session is € 200.

    Listening to the uniquely made-for-you recording for 21 days is an essential part of this process.
    Do you consent to me using your data as per Knot Undone Therapy Privacy Statement?
    Do you understand that making the appointment you are agreeing to the Knot Undone Therapy Terms & Conditions and Knot Undone Privacy Statement?