Mind Wellness Confidential Client Intake Form

    Full Name

    Your Phone

    Street Address

    State (Province) & Country

    Are you currently taking any medication?


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

    Are you currently under the care of another Therapist?


    Have you had Guided Meditation and/or Hypnosis before?


    Are you a smoker?


    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


    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?


    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?


    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?


    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)




    Music provided by Nicolas Byng of Mosaic