Client Intake Form Contact Information Full Name D.O.B Date Home Work Mobile Email Is it OK to contact you at home or work? Yes No Address Street State Postcode How did you hear about me? Friend Search Engine Other How did you hear about me? Are you in a Health Fund? Yes No Which Health Fund? Bupa HCF New Option Do they cover Hypnotherapy? Yes No Health Problems and Medications Are you currently under any treatment from any other medical practitioner for any health problem? Is there any reason you know of that should prevent you from receiving Hypnotherapy Services? Yes No Primary Reason Select from the menu the main reason you have come for. Smoking Cigarettes Success / Achievement Goal Setting Irritable Bowel Panic Attacks Sadness / Depression / Negativity Confidence / Assertiveness Relationships Bereavement / Grief Guilt / Shame Nail Biting / Hair Pulling Fears / Anxiety / Phobia Bruxism / Tinnitus Skin Disorders - Psoriasis / Wars Anger Gambling Sexual Assult Smoking Marijuana Insomnia Food Issues - weight / bulimia Alcohol Problem Concentration / Study & Exams Bed Wetting Phobia / Situational Stress Sexual Stress - Erectile / Vaginitis Migraine Headaches Energy / Motivation Sports Performance Additional Reasons Tick all other issues you are aware of that may also be relevant. Smoking Cigarettes Success / Achievement Goal Setting Irritable Bowel Panic Attacks Sadness / Depression / Negativity Confidence / Assertiveness Relationships Bereavement / Grief Guilt / Shame Nail Biting / Hair Pulling Fears / Anxiety / Phobia Bruxism / Tinnitus Skin Disorders - Psoriasis / Wars Anger Gambling Sexual Assult Smoking Marijuana Insomnia Food Issues - weight / bulimia Alcohol Problem Concentration / Study & Exams Bed Wetting Phobia / Situational Stress Sexual Stress - Erectile / Vaginitis Migraine Headaches Energy / Motivation Sports Performance Relevant Reasons Sexual abuse or rape Psychological abuse Fears from past events Physical abuse Accidents No love in childhood Bullied at school Illness (past or present) Drugs Parents divorced Marriage problems OtherOther What Changes Do You Want? What changes are you hoping to see or feel that will let you know you are achieving what you came here for. Type of Job Stressful? Yes No Background Notes Any illnesses, accidents, any sort of trauma, anxiety, situations that cause you to feel any negative emotions, not covered so far - anything that could prevent you from reaching what you have come here to achieve. Permission It is a requirement under NSW Legislation that I inform you that my practice comes under the NSW Legislation Code of Conduct. You may read the code here - NSW Health Code of Conduct I would request that you give me permission to send details of your success to your Medical Practitioner so that she/he gains trust in my ability to assist other patients. This contact only relates to the outcome of our work and in no way breaches confidentiality in what we have spoken about, i.e. “Client-X has come to me to cease the smoking habit (insomnia, anxiety etc.) and I am pleased to advise that on checking with Client-X that this is no longer a problem for her/him.” Unless you advise me specifically not to do so, putting your Doctors details below is your consent to allow me to contact her/him. Doctor's Name Contact Number Address Sometimes, (though this has rarely been the case in my practice) it may be helpful for you and me to discuss your medical condition with your Medical Practitioner to ensure your safety (Epilepsy for example). By Law, I have an obligation to discuss details with your Medical Practitioner or the authorities without your permission, if you are in danger to yourself, or to anyone else, or if I were subpoenaed by law. This is called mandatory reporting. All doctors/health professionals have an obligation to do this. I would discuss this with you before needing to do so. I have never had a need to do this in my practice to date. A note* “Believe nothing, no matter where you read it or who has said it, not even if I have said it, unless it agrees with your own reason and your own common sense.” ~ Buddah Send Form
