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 "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 (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 a minimum of 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 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 involvment in a serous crime, your therapist, as a Mandatory Reporter is legally obliged to report these incidents is to the relevant authorities. If you are concerned please look up Confidentiality and Mandatory Reporting and arrive fully informed.

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.

I understand and agree

Consent to use Hypnosis (Must be answered)

I agree and I give my informed 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 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

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

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 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.

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):

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

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