Intake & Consent Form

Please fill out the following form.

Practitioner & Data Controller Information

Therapist Name: Selene Emrys-Jones

Practice Name: SEJ Mindshift

Professional Body: Registered Member of the National Hypnotherapy Society

Registration Number: HYP24-00131

Contact Number: 07786 873306

Email Address: selene@sej-mindshift.com

Website: sej-mindshift.com

Business Address: 4 Thorlands, Farnham Lane, Haslemere, GU27 1EZ

ICO Registration Number:

Your Details

First name

Last name

Home Address

Phone

Emergency contact name and phone number

Date of birth

Day

Month

Year

GP Name & Surgery

Terms of Service

The Therapeutic Process: Hypnotherapy is a collaborative process combining therapist guidance and client commitment. While hypnotherapy has an excellent track record for positive change, results vary across individuals and specific outcomes cannot be guaranteed.

Online Session Requirements: For sessions conducted online via video platform, you must ensure you are in a quiet, private room where you will not be disturbed or overheard. A stable internet connection is required. You must not record the sessions without prior written agreement.

Cancellations & Missed Sessions: A minimum of 24 hours' notice is required to cancel or reschedule an appointment (applicable to both face-to-face and online sessions). If you fail to attend, or cancel with less than 24 hours' notice, you will forfeit and lose the full payment for that session.

I confirm that I have read and understood the statements above

Privacy Notice & Data Protection (UK GDPR / DUAA Compliant)

Please read this notice regarding how your personal information and sensitive health records are collected, handled, and securely stored:

Lawful Basis for Processing: I hold and process your personal contact data under the lawful basis of Contract (to provide you with the therapeutic service). I collect and process your session notes, goals, and medical history (Special Category Data) under the basis of Explicit Consent and Legitimate Interests (Article 9 of the UK GDPR).

Data Security & Online Platforms: Hand-written notes are stored in a locked filing cabinet. Digital records are accessed only on password-protected, encrypted devices using secure platforms. Online video sessions are conducted using GDPR-compliant, end-to-end encrypted platforms (such as Zoom/Teams) to ensure transmission privacy.

Data Retention: To comply with professional insurance standards, your physical and digital client file will be retained securely for 6 years after your final session. After this timeframe, your data will be securely shredded and permanently deleted.

Your Rights: Under UK data protection laws, you hold the right to access a copy of your records (via a Subject Access Request), demand corrections to inaccurate data, or ask for your data to be restricted/erased. Note that erasure requests are legally restricted by my insurance-mandated data retention requirements.

I confirm that I have read and understood the statements above

Confidentiality, Online Interruptions & Legal Disclosures

Everything you share within our therapeutic sessions remains strictly confidential. However, there are explicit, legally mandated exceptions where confidentiality must be breached:

Safety & Safeguarding: If I assess that you represent a serious, immediate danger of harm to yourself, to me, or to another member of the public.

Legal Requirement: If ordered to release files, disclose information, or attend a court hearing by a judge or via a valid legal subpoena.
Clinical Supervision: To maintain professional standards, I regularly review my case files with a qualified clinical supervisor. Your identifying details will always be completely anonymised during these sessions.

Online Technical Failure Protocol: If our online video connection drops during a session and cannot be re-established within 5 minutes, I will attempt to contact you via the phone number provided in Section 1 to conclude the session safely.

I confirm that I have read and understood the statements above

Client Consent Declarations

Consent to Therapy: I consent to undergo hypnotherapy treatment with Selene Emrys-Jones and understand the collaborative nature of the practice (whether conducted face-to-face or online)

Consent to Data Processing: I explicitly consent to the collection, processing, and secure storage of my personal and sensitive health notes as outlined in Section 3.

GP Communication: I agree that my hypnotherapist may contact my GP or medical team if it is deemed clinically necessary for multi-disciplinary safety, where practical and permissible.

Emergency Contact: In the event of a medical emergency during a session, I authorise my hypnotherapist to contact emergency services or my designated next of kin.

Marketing & Practice Updates (Optional): I consent to receive occasional newsletters, wellbeing articles, or practice updates from SEJ Mindshift via email.

Is there any other information you wish to devolve that you think your practitioner should be aware of?

Signature

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