Client Intake

Are you currently taking any medication?* YesNo

Are you currently under the care of another Therapist or health care professionals?* YesNo

Which treatments are you seeking?* HypnotherapyPsychotherapyYoga Therapy

Have you had Hypnotherapy in the past?* YesNo

Are you a smoker?* YesNo

Describe your alcohol consumption?* I don't drink at allOccasionallySociallyNot at homeOccasional bingesA glass or two at nightEvery dayI use it to help me sleep

Describe your quality of sleep?* GoodAveragePoorVariable

Have you experienced any of the following? Are you experiencing them now? Tick* DepressionAnxietyChronic InsomniaPhobiasAddictionsCompulsive DisordersDrug AbuseEating DisordersSchizophreniaBipolar DisordersOtherNone of the above

Do you suffer from any of the following?* Respiratory ProblemsDigestive IssuesHigh Blood PressureDizziness/FaintingBack or Neck PainOther Joint pain describePsoriasis/Skin Complaint

What is it that you expect we can help you with?* Performance AnxietySocial AnxietyGeneralised AnxietyWork StressRelationship StressDepressionStop DrinkingTrauma/PTSDBehavioural ModificationAddictionsStudy Skills/MemoryPhobiaPain/Post Operative HealingChronic disease managementImprove physical healthOther

Are you 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

How did you find out about the clinic?* TelevisionDoctor's referralOther TherapistNaturally Therapy pagesGoogleFriendOther

Would you like to be kept informed of workshops that would support and reinforce the work you have done here in the clinic* YesNo

Would you be willing to answer a short questionnaire sometime in the future for research purposes?* YesNo

CLIENT INTAKE FORM

Cancellation Policy: I acknowledge that I, unless I give 24 hours notice of a session cancellation, 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 also recognise that I am seeking alternative/non-medical treatment that may not be supported or endorsed by established medical practice.* YesNo

If seeking hypnosis treatment. Do you consent to the use of hypnosis as a treatment tool during your clinical hypnosis session?* I consent