4A Salisbury Drive, Terrigal NSW 2260
Central Coast NSW Australia
PH: 0423 152 851
Client Intake Form
Have you ever been diagnosed with a mental illness?
Are you on any medication?
If yes, what is the name of the medication?
Are you currently under the care of another therapist?
Have you had hypnotherapy before?
If so, what type of hypnotherapy was it?
Traditional script reading
Neo Ericksonian cognitive or strategic
I don't know
Are you a smoker?
Describe your alcohol consumption.
I don't drink at all
Not at Home
A glass or two at night
I use it to help me sleep
Describe your quality of sleep
Have you ever suffered from any of the following?
None of the Above
Do you suffer from any of the following?
Pain/Post Operative healing
Are you a member of a health fund?
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.
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.
How did you find out about the clinic?
Natural Therapies Pages
Would you like to be kept informed of workshops that would support and reinforce the work you have done here in the clinic?
Would you be willing to answer a short questionnaire sometime in the future for research purposes?
Cancellation Policy: I acknowledge that unless I give 24 hours notice of a session cancellation I may be charged in full.
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 to the use of hypnosis as a treatment tool during my clinical hypnosis session.
Please ensure you have adequate funds on your credit/debit card or cash for the first session.
Please type your First and Last Name.
I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above terms.