Weight Loss Initial Form

About Your Session

Our Weight Loss sessions are held in a relaxed and comfortable setting. The session will leave you feeling motivated and empowered. You will discover that you have a new approach to food and eating, and that you feel much more at peace with yourself. We find that changes can be implemented immediately and are easily sustained.

Full name:

Current weight?

Your Ideal Healthy Weight?:

Who is your current doctor and where do they practice?

Is your doctor aware of this appointment?
YesNo

Has your doctor advised you to lose weight?
YesNo

May I contact your doctor or referring practitioner if required?
YesNo

Have you ever been hypnotised before? (Please provide details)
YesNo

Do you drink alcohol?
YesNo
Type? How often?

Do you smoke cigarettes? YesNo
How many per day?

Do you exercise? YesNo
How often?

Have you ever been diagnosed with an eating disorder?
YesNo

How do you currently feel about your body and your weight?

Why do you want to lose weight now?

Is it portion sizes or specific foods that are a problem?

List a few foods you love:

List a few foods you hate:

Are there specific times or situations when you feel that you overeat?

How would your life be different if you were slimmer & healthier?

What are three positive things you will gain by losing weight?


Does anyone else in your family have issues with weight?