Client Intake Form

Please complete all fields on this form before your first consultation. Thank you.

my first name is

my family name is

my date of birth (DD/MM/YYYY) is

my mobile number is

my email address is

my street address is

my state is
New South WalesACTNorfolk IslandNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia

my postcode is

I am currently taking medication
yesno

*if 'yes', what is it and why was it prescribed?

I am currently under the care of another therapist
yesno

*if 'yes', what is my therapist's name?

I have had hypnotherapy before
yesno

I am a smoker
yesno

my alcohol consumption is:
I don't drink alcoholoccasional drinkersocial drinkerI don't drink at homeoccasional bingesa glass or two at nightevery dayI use it to help me sleep

The quality of my sleep is
goodaveragepoorvariable

I have suffered from the following condition/s:
AddictionAnxietyBipolar DisordersBody ImageChronic InsomniaCompulsive DisordersDepressionDrug AbuseEating DisordersOCDPain ManagementPhobiasPTSDSchizophrenianone of the aboveother

if 'other', please describe

I suffer from the following physical condition/s:
Back or Neck PainDigestive IssuesDizziness / FaintingHigh Blood PressurePsoriasis / Skin ComplaintsRespiratory problemsnone of the above

I expect that you can help me with:
AddictionAnxietyBehavioural ModificationDepressionPain / Post Operative HealingPerformance AnxietyPhobiaRelationship StressSocial AnxietyStop DrinkingStudy Skills / MemoryTrauma / PTSDWork Stressother

if 'other', please describe

I am a member of a health fund
yesno

N.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 disagree

I heard about the clinic via:
Doctor's referralother therapistfriendGoogleother*

if 'other', please describe

My Doctor's name

My Doctor's consulting room address

I would like to be kept informed of workshops that support and reinforce my clinical consultations
yesno

I am willing to answer a short questionnaire (in future), for research purposes
yesno

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

Disclosure: 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
yesno

I recognise that I am seeking alternative / non medical treatment/s which may not be supported or endorsed by established medical practice
yesno

I consent to the use of hypnosis as a treatment tool during your clinical hypnosis session
I consent

I provide the following information which may be relevant

6x2=?