Mind Wellness Confidential Client Intake Form

Full Name


Your Phone


Street Address


State (Province) & Country




Are you currently taking any medication?

YesNo

If Yes, what is it and why was it prescribed?

Are you currently under the care of another Therapist?

YesNo

Have you had Guided Meditation and/or Hypnosis before?

YesNo

Are you a smoker?

YesNo

Describe your alcohol consumption

I don't drink at allOccasionallySociallyNot at homeOccasional bingesA glass or two at nightEvery dayI use it to help me sleep

Describe your quality of sleep

GoodAveragePoorVariable

Have you ever suffered from any of the following?

DepressionAnxietyChronic InsomniaPhobiasAddictionsCompulsive DisordersDrug AbuseEating DisordersSchizophreniaBipolar DisordersOtherNone of the above

Do you suffer from any of the following?

Respiratory ProblemsDigestive IssuesHigh Blood PressureDizziness / FaintingBack or Neck PainPsoriasis / Skin ComplaintsNone of the above

What is it that you expect Mind Wellness will help you with?

To De-StressTo Sleep BetterTo Become Anxiety FreeTo Build ConfidenceTo Find Passion & SuccessTo Live HappierTo Control / Stop AlcoholTo Ease Trauma / PTSDTo Control WeightTo Give Up AddictionsImprove Study Skills / MemoryTo Eliminate PhobiasTo Dissipate pain and Promote HealingTo Quit Bad Habits

What else might you need help with?

Are you a member of a Health Fund?

YesNo

NB: Health fund rebates vary between funds and levels of cover. Additionally, changes in policy can occur at any time. We cannot tell you if your particular insurance policy will cover your hypnotherapy sessions, or what your rebate will be.




How did you find out about Mind Wellness?

FacebookDoctor's ReferralOther TherapistAHA or ASCHGoogleFriendOther

Would you like to be kept informed of workshops that would support and reinforce your overall objectives and outcomes?

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 will be charged in full

I AgreeI Disagree

DISCLOSURE: I understand that if I disclose that I have or intend to commit certain criminal offenses, the Therapist is obliged by law to report me to the authorities

I AgreeI Disagree

I recognise that I am seeking alternative / integrative / complimentary therapy that is, non-medical practice treatment

I AgreeI Disagree




Do you consent to the use of guided meditation, mindfulness, strategic psychotherapy, clinical hypnosis, NLP, and/or coaching as treatment tools for today and further sessions?

I CONSENT




Please use this space to provide any other information you feel may be relevant

Full Name


Date (dd/mm/yy)


Client Signature (use mouse or touchpad)



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