About You

First Name *

Last Name *

Age

Email *

Phone *

Occupation

How did you find out about me?

INTAKE FORM

What has prompted you to consider empowerment life coaching & hypnotherapy? *

What impact is (are) the above issue(s) having on your life? *

What, if anything, have you done already to help deal with this (these) issue(s)? *

As a result of empowerment life coaching & hypnotherapy, how would you like your life to be in one year’s time? *

What do you believe are the consequences if you don’t change anything? *

CONTRACT

This agreement is entered into between Dr Connie Kerali and (full name): *

Dr Connie Kerali is unfortunately unable to offer hypnotherapy for those who currently suffer from, have a history of, or who have been diagnosed with: a Personality Disorder; Schizophrenia, Psychosis, or Delusional symptoms; & Epilepsy or Seizures. *

I confirm that I do NOT have and I have never been diagnosed with any of the above conditions/symptoms

Life Coaching

Life coaching is a partnership between you and your coach. With the use of thoughtful questioning, it affords you the time, space, and guidance to generate new ways of thinking; transform self-limiting beliefs; identify your strengths,values, and purpose; and find solutions to complex issues in your personal and professional life. Coaching is NOT about being given advice or being told what to do as in mentoring. Coaching is NOT therapy. Whilst psychoanalytical therapy focuses on understanding and resolving emotional trauma from the past and the impact on the present, coaching focuses on the present and future.

I understand that coaching is a partnership between myself & my coach: *

Yes

I understand that coaching is NOT mentoring or therapy: *

Yes

I understand that coaching is NOT a substitute for professional medical care: *

Yes

Hypnotherapy

Hypnotherapy (hypnosis) is a partnership between you and your hypnotherapist. It enables you to leave behind external distractions and focus your attention on yourself and what’s happening within. A clinical hypnotherapist acts as a guide, teaching you how to focus your awareness so that you are better able to relax, identify limiting beliefs, release difficult emotions, get to the root cause of a problem, come up with solutions, and make transformational changes.

I understand that hypnotherapy is a partnership between myself & my hypnotherapist: *

Yes

I understand that I will NOT be asleep during hypnotherapy but I will be deeply relaxed with a focused awareness: *

Yes

I understand that hypnotherapy is NOT mind control and I will be in full control throughout the session: *

Yes

I understand that clinical hypnotherapy is NOT the same as stage hypnosis: *

Yes

I understand and accept that hypnotherapy carries the risk of uncovering unpleasant memories, which could cause intense emotional discomfort: *

Yes

I understand that hypnotherapy is NOT a substitute for professional medical care: *

Yes

Sessions, Timings & Locations

All online group coaching & hypnotherapy sessions are up to 2-hours in duration and will occur at least weekly. This coaching and hypnotherapy package has 6 sessions.

I agree to arrive to my sessions on time and understand that if I am late for an appointment my session will be shortened: *

Yes

I understand that it is my responsibility to ensure I have wifi access and a charged device to use for my online appointment: *

Yes

I understand that sessions are not recorded, so I am encouraged to attend all 6 live sessions. *

Yes

Cancellation, Rescheduling & Refunds

No refunds will be issued <48 hours before the Programme has begun. If you withdraw >48hours before the Programme starts, a 5% administrative fee is charged for the refund. If you cannot attend the Programme, you may request to transfer your enrolment to a future cohort (subject to availability). Please email info@drconniekerali.com if you wish to cancel your participation in the Programme.

I understand and agree with the cancellation policy: *

Yes

Roles & Responsibilities

Whilst results can vary from person to person, Dr Connie Kerali can guarantee that she will use the same empathetic, non-judgmental, professional, and holistic approach that she is well known for as a doctor. She will listen to the challenges that you are facing in your own life, and will work together with you to create a tailored empowerment coaching and self-hypnosis program.

I commit to carrying out the pre-/post-session exercises agreed upon with Dr Connie Kerali as well as any post-session or post-programme feedback: *

Yes

I agree to be an active participant in my coaching and hypnotherapy programme: *

Yes

I understand that respect, kindness, and non-judgment are core values of this community. I understand that any behaviour deemed disrespectful, discriminatory, or disruptive may result in removal from the Programme without refund. *

Yes

Confidentiality

Dr Connie Kerali will keep the information that you provide confidential and will never disclose anything you share to a third party without your explicit consent. As is good practice in coaching and hypnotherapy, Dr Connie Kerali undertakes supervision/peer review and may discuss any issues which arise out of our sessions with her supervisor or peers. However, in doing so, the scenarios and conversations around them will be anonymised, so that they contain no identifying information. There are exceptions, where Dr Connie KeraIi will need to disclose certain confidential information to the relevant third party including:

If I consider you pose a threat to yourself or others;
If you raise a concern relating to safeguarding/child protection issues; or
If I am obliged to disclose your confidential information for a legal court case.

I understand and agree with the confidentiality policy: *

Yes

I understand that everything shared within the group is strictly confidential. *

Yes

I agree not to share another participant’s personal information, story, or identity outside of the sessions. *

Yes

Pricing & Payment

The price of the Empowered By My Story beta group programme is £450.

I agree to pay the full amount upfront: *

Yes

Declaration

I agree NOT to record (audio or visual) my session(s): *

Yes

I would like to receive marketing information from Dr Connie Kerali via email: *

Yes

I have read, understood and agree to the Service Terms & Conditions and the Privacy Policy:

Signature *

Clear

Date *