NLP Coaching and Hypnosis Application Form

NLP Coaching and Hypnosis Contract & Online Application

NLP Coach and Hypnotherapist Julia Lee

I am a qualified INLPA (International Neuro Linguistic Programming Training Association) Certificated Master Practitioner of the Art and Science of Neuro Linguistic Programming (NLP) and General Qualification in Hypnotherapy Practice (GQHP) and an ILAM Level 5 Coach.

FAQ's & Your Consent

What you can Expect from the Coaching and Hypnosis?

NLP Coaching and hypnosis looks to empower an individual by helping them make, meet and exceed goals in both their personal and professional lives over an agreed timeframe.
The first NLP Coaching session will look to gain an overall perspective of your life, before identifying which area you seek to improve or are currently unhappy with.

The Coach and you will agree an outcome/Intention that during sessions will be broken down into more achievable goals/Intentions.

It is then down to you to go away to reflect and use any of the techniques you have been taught and work on what has been agreed.

It is between sessions that you must possess the drive and focus to want to change. This will be facilitated by the Coach who during the sessions will change how you look at both yourself and the rest of the world and in time a more positive thought process will be developed.

If you have the desire to change and challenge yourself, you will ultimately achieve your goals.

I am a qualified hypnotherapist I will advise you of the scope of hypnosis/hypnotherapy practice and will only be used in the NLP Coaching with your consent

NLP Coaching and Hypnotherapy Fees

Coaching Sessions: Will normally last between 60 and 90 minutes

During the coaching sessions we will agree the scheduling jointly

If for any reason the session is cancelled, we will meet on the next mutually agreed date and time.

Any changes in circumstances may require a discussion and agreement if any changes are required.

My Commitment to the Coaching Process

  1. As a coach I do not have all the answers, however, I am committed to working with you to explore them and help you identify how you move forward.
  2. I will always do my best to help you achieve all you want for yourself, however, there are no guaranteed results; you get out what you put in.
  3. I will always treat you with respect and what you tell me will be in confidence. There may be occasions when something you share with me needs to be shared more widely, however, we will discuss this first, so you are comfortable with the approach, wherever possible, you will take the lead in sharing the information with others.
  4. I may be asked to feedback generic information regarding issues such as learning needs or other points which may help inform further programmes. I will not feedback any such information if I cannot guarantee confidentiality.
  5. As a coach, I may work with other people who you may or may not know. I will inform you if there is a conflict of interest. Where we work together with this knowledge of others, the focus of our work will be on your situation and your responsibilities. Therefore, I will not refer to situations or any knowledge I have about others gained from my interaction with them.
  6. I will ensure the all personal data is securely stored and will only be used for the coaching sessions. If this change I will discuss it with your first
  7. I am obliged to comply by the National Council for Hypnotherapy (NCH) Bye Laws and Codes of Ethics and to always put you first. The NCH operate a complaint and disciplinary process which can be accessed via; Website or Telephone; 08455440788 or written NCH Ltd, PO Box, York, YO43 4WL

Your Commitment to the Coaching Process

    1. I agree that the main purpose of this coaching agreement is to provide support and maintain or enhance my personal development and performance over an agreed timeframe.
    2. I will ensure that I do this to the best of my ability, I have agreed objectives and action plan set out in the session.
    3. I understand that taking part in this coaching agreement places responsibilities on me.
    4. I agree to prepare for each session, to be punctual and actively participate.
    5. I agree to follow up action plans that I choose to commit to within the coaching session to the agreed timescales.
    6. I understand that all that is discussed between us will be treated in confidence, unless we agree that the information can be shared with another party.
    7. I agree to complete all evaluation forms during and following the final sessions.
    8. I will ensure that the sessions are not interrupted and will give my full attention to the interaction.
    9. I understand that if I cancel a session without due notice I am liable for the full cost of the session.

    Either party can request a termination of this agreement if there is: a breakdown in the coaching process, inadequate commitment or lack of progress.

Hypnosis/Hypnotherapy Consent

  • I have been advised by Julia Lee of the scope of hypnotherapy practice, and I give my full consent to receiving a hypnotherapy session from Julia Lee for the purpose outlined in the history form and for future purposes
  • I understand that results vary, and that the practitioner may not guarantee results. Hypnosis/Hypnotherapy is not a replacement for medical treatment, psychological or psychiatric services or counselling.
  • I understand that the Hypnotist/Hypnotherapist does not treat, prescribe for or diagnose any condition.
  • I understand that the practitioner is a facilitator of hypnosis or hypnotherapy and is not practicing any other profession that requires a license under the laws of England.
  • I am aware and understand that in some cases it may be necessary for the practitioner to respectfully touch my shoulder(s), hand, wrist, or forehead to assist me in relaxation. I give the practitioner permission and consent to do so to help me establish a beneficial state of hypnosis.
  • I have been advised that I am free to terminate any or all sessions at any time.
  • I have accurately provided background information as requested by the hypnotist/hypnotherapist and confirm that I have no conditions that mean hypnosis in contraindicated.
  • I understand that confidentially regarding my sessions will be honored unless the practitioner feels that I or someone else are in danger, in which case disclosures will be kept to a bare minimum necessary for my protection or the protection of a third party.
  • I understand that sessions may be recorded for my own protection and for that of the practitioner.
  • I have been informed that copies of all recordings are available to me but will not be made available to any third party without a court order instructing CSI to make copies available.

NLP Coaching and Hypnosis - Your Details

Your Name (required)

Date of Birth (DD/MM/YYYY)

Age (required)

Address (required)

Telephone Mobile (required)

Telephone Other

Email (required)


MarriedSingleLong Term PartnerDivorcedOther

Number of Children

Age of Children

Child 1

Child 2

Child 3

Hobbies/ Interests


What do you hope to accomplish from sessions?

Is there any part of your past that you do not want to explore (certain ages or experiences)?

Have you been hypnotised before? (required)


If yes, why were you hypnotised?

If yes, how did it go for you?

Medical History - Please answer yes or no and give as much information as possible

Do you have any diagnosed medical illnesses?

GP Name

GP Address

GP Postcode

GP Phone

In cases where a referral is appropriate, I hereby grant permission to contact the above-named person


Have you ever suffered from Depression?


Details of any major operations

Do you have a diagnosed psychological problem?

If yes, Is your GP aware of your psychological problem?


Are you currently taking any drugs/medication?


Details if yes

Have you ever had treatment from a psychologist, Psychiatrist, Hypnotist?

Are you currently having any medical or psychological treatment for any of the above issues?


If yes please give details

Psychologist, Psychiatrist, Hypnotist Title and Name




In cases where a referral is appropriate, I hereby grant permission to contact the above-named person


Please tick any of the following that you would like you work on or that applies to you

Anxiety/StressFearInsecuritySleep/InsomniaGuiltConfidenceSelf EsteemGriefObsessionsAngerPanicPainStudyingAlcoholSmokingSports/PerformanceRelationshipsPhobiasWeightPTSDSuicideDepressionHabitsDrugsBurnoutWork/Performance

By ticking this box. I confirm that, to the best of my knowledge and belief, the above information is true and correct (required)