Client Intake Form

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Have you ever been diagnosed with a mental illness?
Are you on any medication?
Have you had hypnotherapy before?
Do you smoke or vape?
Describe your alcohol consumption
Describe your alcohol consumption
Have you ever suffered from any of the following:
Do you suffer from any of the following?
Are you a member of a health fund?
N.B. Health fund rebates vary between funds and levels of cover. Additionally, changes in policy can occur at any time. We can not tell you whether your insurance policy will cover your hypnotherapy sessions, or what your rebate will be.
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.
How did you find out about the clinic?
Would you like to be kept informed of workshops that would support and reinforce the work you have done here in the clinic?
Would you be willing to answer a short questionnaire sometime in the future for research purposes?
Cancellation Policy: I acknowledge that unless I give 24 hours notice of a session cancellation I may be charged in full.
Confidentiality: Your session is subject to the rules of confidentiality. Nothing you disclose will leave the room or be relayed to others. However. there are exceptions to the rules of confidentiality. Any situation where you are at risk of harming yourself or you reveal your involvement in a serious crime, as a Mandatory Reporter, would be legally bound to report these Incidents to the authorities. If you are concerned please look up Confidentiality and Mandatory Reporting and arrive fully informed.
I also recognise that the therapist will use hypnosis as part of the treatment plan, and that I am seeking alternative/non medical treatment that may not be supported or endorsed by some established medical practice.
I agree to the use of hypnosis as a treatment tool during my clinical hypnosis session.
Term Acceptance