CLIENT INTAKE FORM

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CLIENT INTAKE FORM

INTUIT CLINICAL HYPNOTHERAPY

Full Name *

Gender *

Email *

Date of Birth *

YYYY

Phone *

Email please print clearly *

Address *

Passions/Hobbies *

Presenting Issues *

Have you ever been diagnosed any mental illnesses *

YES

If yes, please specify the conditions

Are you currently taking any medication *

YES

If Yes, what is it and how long have you been taking it?

Are you currently under the care of another Therapist? *

YES

If Yes, please specify. E.g. Hypnotherapist ...

Have you ever had Hypnotherapy before *

YES

If Yes, Was it good experience(s)?

YES

Clear selection

Please give more details on the experiences.

Are you a smoker *

YES

How long have you been smoking

How many cigarettes do you smoke per day

Describe your alcohol consumption *

I don't drink at all

Occational binges

Socially no more than once a week

Socially twice a week

Socially three times or more per week

Occasionally 1 or 2 glasses

I use it to help me sleep

Describe your quality of sleep *

No sleeping issues

Diagnosed Chronic Insomnia

Diagnosed Sleep Apnea

Trouble fall in aleep

Fall in aleep easiy but wake up too early on regular basis

Go through patterns, e.g. good couple of days then run bad cycle

Sleep ok but poor quality

Do you suffer from any kind of Anxiety *

Never

Only when something happens occassionally

Regularly

Experienced Anxiety Attack

What kind of Anxiety are you suffering from

Social Anxiety

Performance Anxiety

Work Stress

Relationship caused

Study

Drinking Withdrawal Syndrome

Drug Withdrawal Syndrome

Other

Clear selection

If Other, please specify

Do you suffer from over-weight *

YES

If Yes, current weight, for how long, reason if known

Do you suffer from any of the following *

Respiratory Problems

Hypertension

Back, and/or neck pain

Dizziness/Fainting

Bipolar Disorder

Phobia

Serious Injuries

Other

Required

If Other, please specify

Work situation *

Full-time Employee

Part-time / Casual Employee

Unemployed under government support

Unemployed with no government support

Business Owner

Profession *

Are you a member of a Private Health Fund *

YES

If Yes, please specify

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 AGREE

I DISAGREE

How did you find out about me *

Referral by my client

From Hypnotherapists Council of Australia Register

From International Strategic Psychotherapy Association Register

From Australian Hypnotherapists Association Register

Google search engine

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

YES

CONFIDENTIALITY: Your sessions with me are all completely confidential. There are situations where, if they present, I will be required to break that confidentiality. You need to be aware of these instances and acknowledge that you are aware of this. Instances where confidentiality will need to be broken: 1. There is the possibility of harm to yourself and/or others. 2. I am required by law (subpoena or for mandatory reporting). 3. For purposes of referral and/or supervision 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. *

I AGREE

I DISAGREE

Please type YES to indicate you understand and acknowledge the above: *

Cancellation Policy: I acknowledge that I, unless I give 24 hours’ notice of a session cancellation, may be charged in full. *

I AGREE

I DISAGREE

I also recognise that I am seeking alternative/non-medical treatment that may not be supported or endorsed by established medical practice. *

I AGREE

I DISAGREE

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

I CONSENT

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

SIGNATURE Please upload your digital signature. If you do not already have a digital signature, please use this link to create one. You will have the option to download the signature and the upload the file here. https://www.signwell.com/online-signature/draw/

Print Name *

Date *

YYYY

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