Newcastle Clinical Hypnotherapy: 1 Powerful Solution For Positive Change

Full Name *

Date of Birth *

Phone *

Email *

Address 1 *

Address 2

City *

State *

Postcode *

Occupation *

Emergency Contact Name *

Emergency Contact Phone *

Relationship to client *

Have you ever been diagnosed with a mental health condition or neurodivergent diagnosis (e.g. Autism, ADHD, SPD, etc)? *

Yes
No

If Yes, please provide details:

Are you on any medication? *

Yes
No

If yes, what is the name of the medication(s)?

Are you currently under the care of another therapist? *

Yes
No

Have you had hypnotherapy before? *

Yes
No

If Yes, what type of hypnotherapy was it?

Traditional script reading
Ericksonian Permissive
Neo-Ericksonian cognitive or strategic
I don’t know

Are you a smoker? *

Yes
No

Describe your alcohol consumption. *

Describe your quality of sleep *

Good
Average
Poor
Variable

Describe your quality of diet *

I mostly follow a healthy diet
I eat too much junk food or sugary foods
My diet is restricted by intolerances or allergies
Some things could be improved

Do you exercise regularly? *

Yes
No

If yes, please describe what activities and how frequently

Do you experience any of the following: *

Have you ever suffered from any of the following? *

What do you expect we can help you with? *

If Other, please provide detail

Have you experienced a significant injury / accident or medical procedure? *

Yes
No

Is there any family history of significant health conditions? *

Are you a member of a health fund? *

Yes
No

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

I Agree
I Disagree

How did you find out about Newcastle Clinical Hypnotherapy? *

If Other, please specify

Cancellation Policy: I acknowledge that, unless I give 48 hours notice of a session cancellation, I may be charged in full. *

I acknowledge I have been advised

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 others or of involvement in a serious crime, your therapist is obligated as a Mandatory Reporter and therefore, legally bound to report these incidents to the authorities. If you are concerned, please look up “Confidentiality and Mandatory Reporting” and arrive fully informed. Your therapist will discuss this with you at your initial consultation. Please acknowledge below. *

I acknowledge that I have been informed of the laws of confidentiality and the mandatory reporting obligations of my therapist.

Clinical Hypnosis consent: I recognise that the therapist will use hypnosis as part of the treatment plan, and I am seeking alternative / non-medical treatment that utilises clinical hypnosis. Please acknowledge below. *

I Agree
I Disagree

Term Acceptance *

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

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Intake Form

Newcastle Clinical Hypnotherapy

Client Intake Form