INTAKE CLIENT INTAKE Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.LayoutLayoutFull Name *Phone *Street Address 1 *Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email *Street Address 2 *LayoutCity *State *Post Code *Are you currently taking any medication? *YesNoIf Yes, what is it and why was it prescribed?Are you currently under the care of another Therapist? *YesNoHave you had any Therapy ? *YesNoWhat is itHypnotherapyPsychotherapyCounsellingAre you a smoker? *YesNoDescribe your alcohol consumption *I Don't drink at allOccasionallySociallyNot at homeOccasional bingesA Glass or Two at NightEvery dayI Use It to Help me SleepDescribe your quality of sleep *GoodAveragePoorVariableHave you ever suffered from any of the following? *DepressionAnxietyInsomniaGrief & LossLow Self EsteemChronic InsomniaPhobiasAddictionsCompulsive DisordersDrug AbuseEating DisordersSchizophreniaBipolar DisordersOtherNone of the aboveDo you suffer from any of the following? *Respiratory ProblemsDigestive IssuesHigh Blood PressureDizziness / FaintingBack or Neck PainPsoriasis / Skin ComplaintsNone of the aboveWhat is it that you Expect We can Help you with? *Performance AnxietyInsomniaGrief & LossSocial AnxietyGeneralised AnxietyWork StressRelationship StressDepressionStop DrinkingTrauma / PTSDBehavioural ModificationAddictionsStudy Skills / MemoryPhobiaPain/Post Operative HealingOtherAre you a member of a health fund? *YesNoN.B. Health fund rebates vary between funds and levels of cover. Additionally, changes in policy can occur at any time. We cannot tell you if your particular insurance policy will cover your hypnotherapy sessions, or what your rebate will be. *I AgreeI DisagreeHow Did you Find out About the Clinic ? *TelevisionDoctor's referralOther TherapistNaturally Therapy PagesGoogleFriendWould you like to be kept informed of workshops that would support and reinforce the work you have done here in the clinic *YesNoWould you be willing to answer a short questionnaire sometime in the future for research purposes? *YesNoCancellation Policy: I acknowledge that I, unless I give 24 hours notice of a session cancellation, may be charged in full.Cancellation Policy: I acknowledge that I, unless I give 24 hours notice of a session cancellation, may be charged in full. *I AgreeI DisagreeDisclosure: I understand that if I disclose that I have or intend to commit certain criminal offenses, the Therapist is obliged by law to report me to the authorities. I Consent Mandatory Reporting will be Required if I Disclose Self Harm, Harm to others, Child abuse and Subpoenaed by Court *I AgreeI DisagreeI also recognise that I am seeking alternative/non medical treatment that may not be supported or endorsed by established medical practice. *I AgreeI DisagreeI also recognise that I am seeking alternative/non medical treatment that may not be supported or endorsed by established medical practice. (copy) *I AgreeI DisagreeDo you consent to the use of hypnosis as a teatment tool during your clinical hypnosis session? *I ConsentPlease use this space to provide any other information you feel may be relevant.Submit
