Equestrian Registration Form - Clinical Hypnotherapy & Performance Psychology for Lasting Change

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Home
- FAQ
- About Me
  - Privacy Policy
Issues Treated
Equestrian
- Equestrian FAQ
  - Equestrian Registration Form
Sport
Fees & Booking
- Registration Form
Contact
Free stuff
Hypnosis Recordings

Book a Discovery Call

Please complete below the Equestrian Client Registration form in the strictest confidence , if however you would prefer to email me a pdf from then please send me an contact form request.

Please also take a moment to read and accept my Terms and conditions

Name

Address

Mobile

Email

DOB

Relationship status

Single Divorced Separated Married Civil partnership

Children (if Yes click)

Occupation

Employer

Self - employed

Self employed

Do you take any exercise Y/N

GP Name and Surgery Address (legally I have to ask)

Do you have any current medical conditions?

Have you had treatments from a Psychiatrist, psychologist, therapist or counsellor?

Psychiatrist Psychologist Therapist Counsellor

If you clicked any of the above please state when and what for?

Any other medical information I should be aware of?

Are you taking any Medication or Drugs?

Yes No

Details of person to contact in case of emergency - (only needed if you are visiting my practice)

If yes please state

Briefly - What is the reason for your consultation?

How long have you had this problem/issue?

Weeks Months Years

Can you pin point the cause?

On a scale of 1 to 10 – how does this disrupt your enjoyment of your riding?

1 2 3 4 5 6 7 8 9 10

On a scale of 1 to 10 – how does this impact other areas of your life?

1 2 3 4 5 6 7 8 9 10

Physical symptoms

Emotional symptoms

Please complete the Tick box below.

1) Any insecurities 2) Low self-esteem 3) Disturbed sleep or insomnia 4) Mood swings 5) Depression 6) Anxiety 7) Lack of concentration 8) Stress 9) Tension headaches

If you ticked any box please give it a score out of 1-5. E.g. the symptom/s being at best –1 and at worst –5.

Please tell me about your horse

Breed

Age

Sex

Time owned

Has this horse contributed to your current problem and how?

Is this horse still contributing to your current issue?

Is there another horse / horses that contributed to this problem?

What have you tried so far to try and make this feeling go away?

Who is your Instructor/Trainer?

How long have you been working with them?

How long have you been working with them?

Do you compete

Yes No

If so what discipline & level?

What level are you working at home?

Do you have any other worries/problems/stress going on in your life right now?

What are you hoping to achieve from receiving therapy?

How would you like to conduct your session? Please tick

Visit my practice in West Chiltington, RH20 2QY. Home visit WhatsApp – number Voice call Face-Time other ?

How did you hear about me ?

Google Search engine other Social media Recommendation Friend Family Word of Mouth

Details of person to contact in case of emergency - (only needed if you are visiting my practice)

Yes accept to sending this information to me

Please note this form is not stored on the internet its is sent direct to my email only!

Yes you accept my T & C's

These can be viewed and download at the top of the page.

Sherree Russell BSc (Hons) Hypnotherapist, Psychotherapist, Emotional resilience trainer & Life Coach Tel 07880 336059

© 2026 All rights Reserved. Sherree Russell

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