Name*

Email*

Date of Birth*

Mobile Phone*

Address 1*

Address 2

City*

State*
ACTNSWNTQLDSATASVICWAOTHER

Post Code*

Emergency Contact*

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

Are you a smoker?*
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?*
TelevisionDoctor's ReferralTherapistNatural Therapies PagesGoogleFriendOther

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, I as a Mandatory Reporter, I 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*

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