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Client Intake Form

Contact Information


Are you currently under any treatment from any other medical practitioner for any health problem?
Select from the menu the main reason you have come for.
Tick all other issues you are aware of that may also be relevant.
What changes are you hoping to see or feel that will let you know you are achieving what you came here for.
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.


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.

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