www.sydneyhypno.com.au - Client Intake Form
Client Information
Full Name
Date of Birth
Date format only - DD/MM/YYYY
Mobile Ph
Numbers only
Email
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?
Yes
No
If YES, please advise what was diagnosed (details here)
Are you currently taking any medications?
Yes
No
If the above answer is YES - If 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 / Colleague
An Association / therapy support group recommendation
Recommendation from workplace
From an internet search
Television
Podcasts / You Tube
From website: www.sydneyhypno.com.au
From the AHA, HCA or other therapeutic practitioners directory
Radio
Other
If the above answer is "Other" - or you wish to nominate who referred you to us, please advise here
Have you had Hypnotherapy before?
Yes
No
Are you a smoker?
Yes
No
Smoker, currently In the process of giving up
Describe your alcohol consumption (Select one or more please)
I do not drink at all
I drink occasionally (Socially with others)
I don't drink by myself (only socially)
I drink to help me sleep
I will drink when by myself regularly
I have occasional binges (once or maximum twice per year)
I will have a glass or two each night (wine or beer)
I only have one glass per night (wine or beer)
I have regular monthly binges
I have regular weekly binges
I have daily or nightly binges
Other (You will be provided space to describe this or added details)
If the above answer is "Other" - or you wish to give details about your choice, please advise here
Describe your quality of sleep
Good
Average
Poor
Variable
Other (you will be provided space to describe this)
If the above answer is "Other" - or you wish to give details about your choice, please advise here
Have you ever suffered from any of the following? (Select one or more please)
Addictions
Anxiety
Bipola Disorders
Chronic Insomnia
Chronic Pain
Compulsive Disorders
Depression (Clinical / Diagnosed)
Drug Abuse
Eating Disorders
Phobias
PTSD / Trauma
Schizophrenia
None of the above/Other
Do you currently suffer from any of the following? (Select one or more please)
Behavioural Issues
Depression
Drinking Issues (Binging / Alcoholism / other )
Generalised Anxiety
Sleep issues
Pain / Post operative healing
Performance Anxiety
Phobia
Relationship Stress
Social Anxiety
Trauma / PTSD / Complex PTSD
Work Stress
Other
Do you suffer from any of the following? (Select one or more please)
High Blood Pressure
Dizziness / Fainting
Back or Neck Pain
Psoriasis / Skin Complaints
Cardiac Issues
Gastro-intestinal Issues
Bruxism / Teeth Grinding (related Facial, neck, head, shoulder pain)
None of the above
What is it you expect we can help you with?
Anxiety
Behavioural Modification
Trauma / PTSD
Addictions
Study Skills / Memory / Focus
Stop Smoking
Stop Grinding your Teeth (Bruxism)
Phobias / Fears
Pain / Chronic Pain / Post Operative Healing
Weight Loss / Weight Management
Performance Anxiety / Public Speaking
Performance Enhancement / Focus
IBS (Iritable Bowel Syndrome)
Other Gastric Related Issues
Other (Space provided for you to advise of expand on options selected)
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?
Yes
No
Would you be willing to answer a short questionarre sometime in the future for research purposes?
Yes
No
www.SydneyHypno.com.au
(ABN 34 137 510 751)
Kerry Bailey m: 0412-412-881
reCAPTCHA helps prevent automated form spam.
The submit button will be disabled until you complete the CAPTCHA.
Contact Information