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Client Intake Form

Please Complete
Are you currently taking any medications?
Are you currently under the care of another Therapist?
Have you had Hypnotherapy previously?
Are you currently Smoking or Vaping?
Describe your Quality of Sleep
Describe your Alcohol consumption
Do you suffer from any of the following?
Have you suffered from any of the following?
What are you expecting we can help you 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.

I have read and agree to the above
Would you like to be informed of workshops that would support and reinforce the work you will do here in Clinic
Would you be willing to answer a short questionaire sometime in the future for research purposes?
How did you hear about Think Well?

Cancellation Policy

I acknowledge that, unless I give a minimum of 24hours notice of a session cancellation, I will forfeit the session and be charged the full fee.

Breach of Confidentiality Disclosure

I acknowledge that if I, disclose that I have or am about to commit a criminal offence that as a Mandatory Reporter the therapist is bound by law to report this to the authorities

Hypnotherapy Consent

I consent to the use of Hypnotherapy as a treatment tool in my sessions.

Release of Information (Optional, based upon specific situation):

The Therapist engages in Coaching training and continuing education pursuing and/or maintaining ICF (International Coach Federation) Credentials. That process requires the names and contact information of all Clients for possible verification by ICF. 

By signing this agreement, you agree to have only your name, contact information, and start and end date shared with the ICF for the sole and necessary purpose of verifying the relationship; no personal notes will ever be shared. 

Thank you, see you in session

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