Every Life Is A Piece Of Art Put Together With All Means Available

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

Have you ever been diagnosed with a mental illness? *

Yes

No

Are you currently taking any medication *

Yes

No

Are you currently under the care of another Therapist? *

Yes

No

Have you ever had hypnotherapy before *

Yes

No

Do you smoke? *

Yes

No

Which of the following best describe your alcohol consumption *

I don't drink at all

Occasionally

Socially

Not at home

Occasional binges

A glass or two at night

Everyday

I use it to help me sleep

How would you describe your quality of sleep *

Excellent

Good

Average

Poor

Terrible

It varies

Have you suffered from any of the following *

Depression

Anxiety

Chronic Insomnia

Addictions

Compulsive Disorders

Eating Disorders

Bipolar Disorders

Schizophrenia

Other diagnosed

None of the above

What are you expecting we can help you with? *

Anxiety

Social Anxiety

Performance Anxiety

Stress/Work Stress

Procrastination/Motivation

Depression

Phobia

Pain management

Trauma/PTSD

Something else

Are you a member of a Private Health Fund? *

Yes

No

HEALTH CARE FUND REBATE: 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. It is your responsibility to check with your healthcare fund *

I agree

I disagree

I am not a member of a Private Health Fund

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 agree

I disagree

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.

NON-MEDICAL TREATMENT: 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

I disagree

HYPNOSIS CONSENT: I agree to the use of hypnosis as a treatment tool during my clinical hypnosis session. *

I agree

I disagree

THERAPIST CARE: I understand that is my responsibility to make any medical practitioner/therapist, that I am currently under the care of, aware that I am undertaking this alternative/non-medical treatment *

I agree

I disagree

CANCELLATION POLICY: I acknowledge that unless I give 24 hours notice of a session cancellation I may be charged in full. *

Yes

No

Would you be willing to answer a short questionnaire sometime in the future for research purposes?

Yes

No

TERMS ACCEPTANCE *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above terms.

Please type your First and Last Name *

First Name

Last Name