Intake Form

Name *

DOB *

Mobile Phone *

Email *

Address 1 *

Address 2

City *

State *

Post Code *

Emergency Contact *

Have you ever been diagnosed with a mental illness? *

Yes
No

Are you on any medication? *

Yes
No

If yes, what is the name of the medication?

Are you currently under the care of another therapist? *

Have you had hypnotherapy before? *

Yes
No

What type of hypnotherapy was it?

Traditional script reading
Ericksonian Permissive
Neo Ericksonian cognitive or strategic
I don't know

Are you a smoker? *

Yes
No

Describe your alcohol consumption. *

Describe your quality of sleep *

Good
Average
Poor
It varies

Have you ever suffered from any of the following? *

Do you suffer from any of the following? *

Are you a member of a health fund? *

Yes
No

N.B. Health fund rebates vary between funds and levels of cover. Additionally, changes in policy can occur at any time. We can not tell you whether your insurance policy will cover your hypnotherapy sessions, or what your rebate will be. *

I Agree
I Disagree

MEDICAL DISCLOSURE. I have pursued all reasonable medical avenues to deal with the presenting issue, and have been informed by my medical practitioner that it is not physical but a psychosomatic issue, or alternatively, it is a physical issue but there is nothing more the medical system can do for me. *

I Agree
I Disagree

How did you find out about the clinic? *

Would you like to be kept informed of workshops that would support and reinforce the work you have done here in the clinic? *

Yes
No

Would you be willing to answer a short questionnaire sometime in the future for research purposes? *

Yes
No

Cancellation Policy: I acknowledge that unless I give 24 hours notice of a session cancellation I may be charged in full. *

Yes
No

Confidentiality: Your session is subject to the rules of confidentiality. Nothing you disclose will leave the room or be relayed to others. However. there are exceptions to the rules of confidentiality. Any situation where you are at risk of harming yourself or you reveal your involvement in a serious crime, I as a Mandatory Reporter, I would be legally bound to report these Incidents to the authorities. If you are concerned please look up Confidentiality and Mandatory Reporting and arrive fully informed. *

I am fully informed of the laws of confidentiality and the mandatory obligations of my therapist.

I also recognise that the therapist will use hypnosis as part of the treatment plan, and that I am seeking alternative/non medical treatment that may not be supported or endorsed by some established medical practice. *

I Agree
I Disagree

I agree to the use of hypnosis as a treatment tool during my clinical hypnosis session. *

I Agree
I Disagree

Please ensure you have adequate funds on your credit/debit card or cash for the first session.

Please type your First and Last Name. *

Term Acceptance *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above terms.

Today's Date *

Client Intake Form