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Counsellor Intake

Intake form

Help me to prepare before our first session

Intake forms allow me to streamline and tailor our sessions to better fit your needs.

This form will allow for a much more efficient use of our session time. 

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Please complete the form before our first session​​

Intake form

Please fill out the following form.

Date of birth
Day
Month
Year
Have you ever been diagnosed with a mental illness?
Yes
No
Are you on any medication?
Yes
No
Are you currently under the care of another clinician?
Yes
No
Have you had hypnotherapy before?
Yes
No
Are you a smoker?
Yes
No
Describe your alcohol consumption.
Describe your quality of sleep.
Good
Average
Poor
It varies
Have you ever suffered from any of the following?
Are you a member of a health fund?
Yes
No
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 rebate will be.
I acknowledge
Medical disclosure. I have pursued all reasonable medical avenues to deal with the presenting issue. My medical practitioner informed me it is not physical but a psychosomatic issue. Or there is nothing more the medical system can do for my physical issue
I Acknowledge
Would you be willing to answer a short questionnaire sometime in the future for research purposes?
Yes
No
How did you find out about the clinic?

For further concerns research Confidentiality and Mandatory Reporting prior to our session

Today's date
Day
Month
Year
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