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

my postcode is

I am currently taking medication

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

I am currently under the care of another therapist

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

I have had hypnotherapy before

I am a smoker

my alcohol consumption is:

The quality of my sleep is

I have suffered from the following condition/s:

if 'other', please describe

I suffer from the following physical condition/s:

I expect that you can help me with:

if 'other', please describe

I am 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 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

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

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

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

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

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