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Have you ever been diagnosed with a mental illness?* YesNo
Are you on any medication?* YesNo
If yes, what is the name of the medication?
Are you currently under the care of another therapist?*
Have you had hypnotherapy before?* YesNo
What type of hypnotherapy was it? Traditional script readingEricksonian PermissiveNeo Ericksonian Cognitive or StrategicI don't know
Do you smoke or vape?* YesNo
Describe your alcohol consumption.* I don't drink at allOccasionallySociallyNot at HomeOccassional BingesA glass or two at nightEverydayI use it to sleep
Describe your quality of sleep.* GoodAveragePoorIt varies
Have you ever suffered from any of the following:* DepressionAnxietyChronic InsomniaAddictionsCompulsive DisordersDrug AbuseEating DisordersSchizophreniaBipolar DisordersOtherNone of the Above
Do you suffer from any of the following?* Performance AnxietySocial AnxietyGeneral AnxietyWork StressRelationship StressDepressionStop DrinkingTrauma / PTSDBehavioural ModificationAddictionsPhobiaPain / Post Operative HealingOther
Are you a member of a health fund?* YesNo
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.* I AgreeI Disagree
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 AgreeI Disagree
How did you find out about the clinic?* Social MediaDoctor's ReferralTherapistGoogleFriendOther
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 questionnaire sometime in the future for research purposes?* YesNo
Cancellation Policy: I acknowledge that unless I give 24 hours notice of a session cancellation I may be charged in full.* YesNo
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 am fully informed of the laws of confidentiality and the mandatory obligations of my therapist.
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 AgreeI Disagree
I agree to the use of hypnosis as a treatment tool during my clinical hypnosis session.* I AgreeI Disagree
Please ensure you have adequate funds on your credit/debit card or cash for the first session.
Please type your First and Last Name.*
Term Acceptance* I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above terms.
Today's Date*