Weight Loss Pre-assessment Form

Can hypnotherapy can help you lose weight?

By completing this form it allows us to get a better idea of your eating behaviours. This will allow us to give you a detailed report on how we think our programme will help you change your behaviours around food. This is not an automatic process. Each form is inspected by a weight loss specialist. It may take up to 24 hours for us to analyse your form. Please be patient.

We will email you back a personalised report on the issues that need addressing and how we would go about addressing them.

Do you know what your decision points are?

We all have decision points about food. For instance if you have a packet of biscuits in the cupboard the decision point is not when you open the cupboard door. It’s when you walk into the supermarket. We will help you identify them and deal with them.

Complete this simple form to start a more appropriate eating behaviour?

    Your Age ------------------
    Your Height ---------------
    Your Current Weight -----
    Your Desired Weight ----

    If you are currently on a "diet"
    please state the name of diet

    Time-scale to achieve desired weight loss

    Types of eating related issues (please tick all that apply)

    Your Name (required) -
    Your Postcode ----------
    Your Email (required) -----
    Your Phone No (required)

    Which clinic would you prefer?

    Please call me

    Any Further Information

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    What Type of Eater Are You?