4A Salisbury Drive, Terrigal NSW 2260
Central Coast NSW Australia
PH: 0423 152 851
Client Intake Form
Name
DOB
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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?
Yes
No
Have you had hypnotherapy before?
Yes
No
If so, 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.
I don't drink at all
Occasionally
Socially
Not at Home
Occasional Binges
A glass or two at night
Everyday
I use it to help me sleep
Describe your quality of sleep
Good
Average
Poor
It varies
Have you ever suffered from any of the following?
Depression
Anxiety
Chronic Insomnia
Addictions
Compulsive Disorders
Drug Abuse
Eating Disorders
Schizophrenia
Bipolar Disorders
Other
None of the Above
Do you suffer from any of the following?
Performance Anxiety
Social Anxiety
General Anxiety
Work Stress
Relationship Stress
Depression
Stop Drinking
Trauma/PTSD
Behavioural Modification
Addictions
Phobia
Pain/Post Operative healing
Other
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?
Television
Doctor's Referral
Therapist
Natural Therapies Pages
Google
Friend
Other
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
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