www.sydneyhypno.com.au - Client Intake Form

Client Information

Full Name

Date of Birth

Date format only - DD/MM/YYYY

Mobile Ph

Numbers only

Address in Full:

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?

YesNo

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

Are you currently taking any medications?

YesNo

If the above answer is YES - you are taking medications, What medications and why where they prescribed?

How did you find out about our clinic?

Referral from GP / Therapist, / Specialist Referral from Family, / Friend / ColleagueAn association / therapy support group recommendation / suggestionRecommendation from workplaceFrom an internet searchOther

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

Are you a member of a health fund?

YesNo

If the above is "Yes" please nominate your Health Fund provider name here

Health Funds (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 (must be answered):
I acknowledge that, unless I give 24 hours’ notice of a session cancellation, that I may be charged in full

I understand and agree

Privacy & Disclosure (Must be answered):
I understand that the Therapist is bound by all Privacy related laws and governances. I also acknowledge that Therapists are Mandatory Reporters and as such, I also understand that if I disclose that I have, or intend to, commit certain criminal offences, that the Therapist is obliged by law to report this to the relevant authorities.

I understand and agree

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.

I understand and agree

Consent to use Hypnosis (Must be answered)

I consent to the use of Hypnosis as a treatment tool during sessions

Video Sessions may be used as & when required due to physical distance requirements - so please nominate which Apps you have or can use in the space provided please:
i.e. FaceTime (iPhone/iPad), WhatsApp (Apple & Android), Zoom, Facebook PM (Video), Teams, Skype or other (please advise)

Please use this space to provide any other information that you feel may be relevant

Please type your First and Last name (Must be answered):

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

Yes

Electronic date/submission date: (Must add in this date)

PHYSICAL/MEDICAL CONDITIONS (Must be understood and answered)

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 minimise 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.

I understand and agree

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 will be accepted when you proceed with the session)

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

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

Contact Information