Sydney Strategic Therapy – Hypnotherapy & counselling

Client Intake

CLIENT INTAKE FORM

    Are you currently taking any medication?*
    Are you currently under the care of another Therapist or health care professionals?*
    Which treatments are you seeking?*
    Have you had Hypnotherapy in the past?*
    Are you a smoker?*
    Describe your alcohol consumption?*
    Describe your quality of sleep?*
    Have you experienced any of the following? Are you experiencing them now? Tick*
    Do you suffer from any of the following?*
    What is it that you expect we can help you with?*
    Anything else I should know about your physical health e.g. pregnancy, constipation, orthopaedic injuries, chronic pain, headaches, arthritis, diabetes please describe……
    By signing below, you agree to the following. I have completed this form to the best of my ability and knowledge and agree to inform my therapist if any of the above information changes at any time. The client acknowledges
    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 cannot tell you if your particular insurance policy will cover your hypnotherapy sessions, or what your rebate will be.*
    How did you find out about the clinic?*
    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?*

    CLIENT INTAKE FORM

    Cancellation Policy: I acknowledge that I, unless I give 24 hours notice of a session cancellation, 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 also recognise that I am seeking alternative/non-medical treatment that may not be supported or endorsed by established medical practice.*
    If seeking hypnosis treatment. Do you consent to the use of hypnosis as a treatment tool during your clinical hypnosis session?*
    Please use this space to provide any other information you feel may be relevant.

    Ready to get started?

    Are you ready to ditch the diets and try something that could change your life permanently for the better?

    You can start by booking a free 20-minute consultation with Kim, our clinical hypnotherapist. She can discuss your goals with you and answer any questions.