www.sydneyhypno.com.au - Client Intake Form

Hello and thank you for completing this Client Intake Form.

This form is an important first step for us. as it allows me to really assist you to help you get the results you want. As the unique individual you are, knowing these answers will help me to design a tailored program to identify the goals and outcomes we will work together to achieve.

To ensure I get all of the important details so we are working within scope, there will be some questions where I will require a response in on the form. Those questions you will see as you go along, will say that an ""Answer is required" - Please note that the form can't be submitted until those questions are answered . (as they are also an important part of my requirement as your therapist to be as a fully informed as possible to provide proper Duty of Care)

If you have any issues with the form - please call on 0412-412-881 - or email kerry@sydneyhypno.com.au and I will call you back to assist you with this process if you need this help. (please let me know on your message what would be a good time to call back as I will be calling back in between client sessions)

I look forward to our working together to reach your goals!

Thank you again,

Kerry

SydneyHypno

Client Information

Full Name (Answer required)

Date of Birth (Answer required)

Date format only - DD/MM/YYYY

Mobile Ph (Answer required)

Numbers only

Email (Answer required)

Address in Full (Answer required)

Full Address please, Street #, Street Name , Suburb, State & Country

Preferred time & phone number etc - to be contacted (to discuss your needs & session/appointments)

Full Address please, Street #, Street Name , Suburb, State & Country

Are you currently under the care of another health care providor?

GP (General Practitioner)Therapist (Please nominate in space provided)Specialist (please nominate in space provided)

Per above- Please advise your GP's name & phone number if possible - plus any details as to Therapist or Specialist can be added here too

Have you ever been diagnosed by any doctor with a mental illness? (Answer required)

YesNo

If YES, please advise what was diagnosed (details here)

Are you currently taking any medications? (Answer required)

YesNo

If the above answer is "Other" - or you wish to nominate who referred you to us, please advise here

Have you had Hypnotherapy before?

YesNo

Are you a smoker?

YesNoSmoker, currently In the process of giving up

If the above answer is "Other" - or you wish to give details about your choice, please advise here

Do you suffer from any of the following? (Select one or more please)

If the above answer is "Other" - or you wish to give details about your choice, please advise here

Health Fund Member - If you are a member of a health fund - please provide its name here:

Health Funds (Acknowledgment of your Understanding):
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 may be.

I understand and agree

Session Cancellations (Answer Required):
I acknowledge that, unless I give a minimum of 24 hours’ notice of a session cancellation, that I may be charged in full

I understand and agree

Privacy & Disclosure (Answer required):
I understand that the sessions are bound by all Privacy related laws and governances. Your Session is subject to the rules of confidentiality. Nothing you disclose will leave the session or be relayed to others. However, there are exceptions to these rules of confidentiality. Any situation, where you are at risk of harming yourself or others or your involvement in a serious crime, your therapist, as a Mandatory Reporter is legally obliged to report these incidents is to the relevant authorities. Therefore: I understand that if I disclose that I have, or intend to commit certain criminal offences, the therapist is obliged by law to report me to the authorities. I further understand that when there is a requirement to refer clients that there are aspects of my treatment plan that may be provided to other health providers for ongoing care treatments. (If you are concerned please look up Confidentiality and Mandatory Reporting and arrive fully informed). You may also ask your therapist to clarify any points prior to proceeding with treatments. (Answer required)

I agree & am fully informed of the laws of confidentiality and the mandatory obligations of my therapist

Use of hypnosis as part of therapy: (Must be answered): I understand that the Therapist will use hypnosis as a part of the treatment plan and that I am seeking alternative / Non-medical treatment that may not be supported by or endorsed by established medical practice. Further to this, I also understand that as part of my therapy I will be asked to complete homework, which is designed to help me to be fully engaged with my therapeutic process. I also understand that I am responsible for and expected to, complete any tasks or homework. I acknowledge, the more I engage in my therapy process, the more I will progress towards my therapeutic goals.(Answer required)

I understand and agree

Consent to use Hypnosis (Answer required) Informed Consent: It is important that you clearly understand and agree to the therapy. If you have any questions about the therapy being provided, please ask your therapist so that you are fully informed and give your consent to therapy. Proceeding with the therapy in your sessions is deemed as your consent a you could cease the session at any time. Note: In agreeing to the above, please be aware that if you have matters to discuss with your therapist, that may include any pending court action, please seek legal advice regarding that matter and its discussion, prior to raising that specific issue with your therapist. (Your therapist will treat details as confidential, but your legal counsel may instruct you to be clear about what areas you will need to exclude from Hypnotherapy in some unusual circumstances. It is your choice to discuss any specific topics with your therapist and should be aligned with your understanding that your informed consent has been given by you and is accepted. It is important to also be aware that if you do have any pending action/court related issues, that you can still seek assistance from your therapist, who may instead utilise other modes of therapy for that identified aspect, including but not limited to Strategic Psychotherapy, NLP, Generative Coaching, EFT, CBT etc, but with the clarity that for those issues identified by you, per the above, is to be excluded from the hypnotherapy component of your care by your therapist. (In relation to the "Per se exclusion rule 'regards hypnotising a witness and their testimony'' use in some courts in the USA) NB: (Answer required)

I agree and I give my informed consent to the use of Hypnosis as a treatment tool during sessions

Informed Consent to Teletherapy/Telehealth Services:

Video Sessions known as Telehealth or Teletherapy may be used as & when required due to physical distance requirements (Sydney Hypno is based in Australia)

PROVISION OF A TELETHERAPY SERVICE: Teletherapy services includes therapy sessions provided by video or phone call, with preference for video call as this is closest to in-person therapy sessions. Once a Teletherapy session is scheduled your therapist will email you a secure link to be able to connect to your Teletherapy session with your SydneyHypno Therapist via the Teletherapy platform used.

No software needs to be downloaded. Teletherapy services require clients to have a secure and reliable internet connection and a device (i.e., smartphone, iPad, laptop, desktop etc) with a camera, microphone and speakers.

It is advisable for clients to choose an environment for each session where they are not likely to be distracted, interrupted or overheard, and one that has minimal noise disturbance.

Clients are encouraged to also choose an environment with good lighting and consideration of the background as it may be visible to SydneyHypno therapist. Because clients may be in varied locations for their Teletherapy sessions, SydneyHypno will require clients to provide their location at the commencement of each session.

Please be aware that clients are responsible for any costs associated with setting up the technology needed so they can access Teletherapy services and their data or call usage. SydneyHypno will be responsible for the cost associated with the platform used to conduct Teletherapy services.

Clients should be aware that problems may occur due to connection issues causing image delays or less than optimal image quality. Video calls generally limit the amount of nonverbal information exchanged between therapists and clients and as a result, there is greater potential for misinterpretation.

Clients are asked to please have patience with the process and clarify information if they think the SydneyHypno therapist has not understood them well and to also be patient if she asks for periodic clarification. Please note that SydneyHypno therapist will be taking notes and at times will need to look down during Teletherapy sessions to record these.

In accordance with legislative requirements, electronic records and paper records are kept in secure storage. SydneyHypno therapist will not make video or audio recordings of Teletherapy sessions and clients are asked to respect SydneyHypno therapist’s privacy by agreeing not to make such recordings of Teletherapy sessions and not to use materials from the sessions for purposes other than therapy (e.g., posting any portion of said sessions on internet websites such as Facebook or YouTube is not permitted).

PROCEDURES IN CASE OF TECHNICAL DIFFICULTIES OR DISRUPTIONS IN SERVICE: If there is ever a disruption of services on the internet or technical difficulties SydneyHypno therapist will message or call the client to discuss how to proceed with the session. If reconnection is not possible within 10 minutes SydneyHypno therapist will send an email to schedule a new session time.

PRIVACY: The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used. To support the security of your personal information SydneyHypno therapist uses up-to-date security software and a HIPAA, GDPR, PHIPA/PIPEDA, & HITECH compliant teletherapy service which is inclusive of end-to-end encryption to protect your privacy. AGREEMENT: By agreeing to participate in a Teletherapy session, I agree to expressly release SydneyHypno therapist from any liability associated with unintended cyber security issues and/or difficulties with unsecured communications.

(Electronic Signature at the end of this form &/or your proceeding with a Telehealth session indicates your consent)

If you wish, please nominate which Devices & or Apps you have or can use in the space provided please:
- Note that our preferred Telehealth platform is simple to use, very secure and able to be used on any device with no downloads or special apps - so we will generally default to :
doxy.me/SydneyHypno - Alternatively we also use ZOOM (and invitation will be sent) other often used platforms are: WhatsApp, FaceTime, Facebook Video, etc

If you are currently working please advise what kind of work that you do, or what work you have done in the past - It is also helpful to know what hobbies and pastimes you really enjoy, and to also use this space to provide any other information that you feel may be relevant

PHYSICAL/MEDICAL CONDITIONS (Must be understood and answered as Answer required)

If your presenting issue manifests with physical symptoms, we cannot treat you unless you can show us that you have been cleared of any underlying physical issues. Problems like constant headaches or migraines, back and neck pain, tinnitus, irritable bowel syndrome, psoriasis, alopecia, bedwetting, allergies, eczema, weight loss, restless leg, immune system deficiencies, cancer and alike must first be checked with a medical professional, and a medical reason for the issue has been discounted before we can treat you ethically.

N.B. Sometimes people’s philosophies about the root cause of an issue can preclude investigating appropriate answers to the issues. For some people everything has an emotional root. We are not of this opinion, and such extreme views can be harmful.

This caveat is demanded out of our duty of care. For example, we want to know that headaches are not a symptom of a larger more serious issue that will be ignored if we help you minimize the discomfort. We will want to see evidence of your medical history and may wish to speak to your doctor about your treatment options. Our preference is that we see you with your GP’s knowledge and cooperation.

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.

(Answer required)

I understand and agree

Terms Acceptance: I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to signing the above terms. (where possible I also agree to signing and dating the hard copy document which will be compiled from this online form )

Yes. I agree & accept the terms and that this constitutes my legal signature.

Please type your First and Last name (Must be answered -Type name required)

Electronic date/submission date: (Must add in this date -Answer required)

Your nominated Emergency Contacts Name & their Mobile number (required)

Signed: (To be done in person at your first session - If Applicable - Note in the event of a tele-health video session, your consent to proceed / continue will be accepted as formal consent, when you proceed with the session)

Dated: (To be done in person at your first session - If Applicable)

Please ensure you have adequate funds on your credit/debit card or cash for the first session

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 questionarre sometime in the future for research purposes?

YesNo

www.SydneyHypno.com.au (ABN 34 137 510 751) Kerry Bailey m: 0412-412-881

Contact Information