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Canberra Hypnotherapy Clinic

Intake form

All the details collected here are required for your first session and save you time so we can get straight into helping you on your first session. Answer them to the best of your ability and rest assured that we will take care of your details.

Personal Details
First Name*
Lastname:*
Date of Birth:*
Phone*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Background
Are you currently on any medication*
- Yes
- No
What medication are you current using
Have you ever had hypnotherapy before?
- Yes
- No
Are you a smoker?
- Yes
- No
Describe your alcohol consumption
Describe your quality of sleep
Have you suffered from any of the following?*
- Anxiety
- Depression
- Schizophrenia
- Bipolar
- Chronic Insomnia
- Phobias
- Addictions
- Compulsive disorders
- Drug abuse
- Eating disorders
- Other
Please provide details
Please provide us with some basic details about your condition such as what it is, how or when it began and any other relevant information that you think would be helpful.
Do you suffer from any of the following?*
- Respitory problems
- Digestive issues
- High blood pressure
- Migraines
- Dizziness/fainting
- Back or neck pain
- Psoriasis/skin complaints
- None of the above
Select all that apply.
What is it that you expect we can help you with?*
- Performance anxiety
- Social Anxiety
- Generalised anxiety
- Work stress
- Relationship stress
- Depression
- Insomnia
- Quit smoking
- Stop drinking
- Addictions
- Behavioural modification
- Trauma/PTSD
- Phobia
- Study skills/memory
- Pain/Post-operative healing
- Other
Select all that apply
Please provide details
Are you a member of a health fund?
- Yes
- No
Note: Health fund rebates vary between health funds and levels of cover. In addition, changes in policy can occur at any time. The Canberra Hypnotherapy Clinic cannot tell you if your particular insurance policy will cover your hypnotherapy sessions, or what the rebate will be.
How did you find out about us?
- Internet
- Natural Therapy Pages
- Other therapist
- Friend
- Other
How?
Type of appointment that would suit you
- Face to face (in Canberra/Sydney)
- Online Session
- Either
I recognise that I am seeking alternative/non-medical treatment that may not be supported or endorsed by established medical practice.*
- I Agree
- I Disagree
Comments
This field is for validation purposes and should be left unchanged.

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