TranceForm Your Life. Call (02) 9543 4433.
I [insert name below]
am the legal parent/guardian of [insert full name of child below]
Date of Birth of Child
Preferred Contact Number
Email (must be completed)
Address
Does your child have any hobbies or interests?
1. Is your child currently taking any medication? YesNo
2. Are you currently under the care of a Medical Practitioner and/or Therapist? YesNo
3. Has your child ever been diagnosed with a mental illness? YesNo
4. Has your child ever had Hypnotherapy before? YesNo
5. What are you expecting we can help your child with?
6. On a scale of 1 to 10, how eager is your child to make change to their situation right now?(Where 10 is extremely eager and 1 is not eager at all). Mark one. 12345678910
7. How would you describe his/her quality of sleep? ExcellentGoodAveragePoorTerribleIt variesI don't know
8. Please list, if any, your child's allergies:
9. How is you child's general physical health? GoodAveragePoor
10. How is your child's mental health? GoodAveragePoor
11. How is your child's emotional health? GoodAveragePoor
12. Has your child ever suffered from any of the following: DepressionAnxietySocial AnxietyPhobiasChronic InsomniaAnger ManagementEating DisordersAddictionsCompulsive DisordersChronic PainBipolar DisordersSchizophreniaPersonality DisorderOther diagnosedNone of the above
If other, please provide details:
The therapy we provide at inTrance Therapy does not replace or is in any way a substitute for proper medical care from a qualified health care practitioner.
Please accept this disclosure to proceed with treatment:
Yes, I accept Clinical Hypnotherapy & Strategic Psychotherapy is not a substitute for proper medical care.
I have pursued with my child all reasonable medical avenues to deal with the presenting issue, and have been informed by my medical practitioner that it is not a physical but a psychosomatic issue:
I agreeNot applicableI disagree, because:
I also recognise that inTrance Therapy will use Hypnosis as part of the treatment plan, and that I am seeking alternative/non-medical treatment for my child that may not be supported or endorsed by some established medical practice.
I agreeI disagree
I understand that it is my responsibility to make any medical practitioner/therapist, that my child is currently under the care of, aware that we are undertaking this alternative/non-medical treatment.
Health fund rebates vary between funds and levels of cover. Additionally, changes in policy with regards to your cover can occur at any time. We cannot tell you if your particular health fund/health insurance policy will cover your Clinical Hypnotherapy/Strategic Psychotherapy sessions.
Yes, I accept that I will need to do my own research into my health funds coverage.
Everything you or your child say in clinic will be kept confidential. The circumstances change only if subpoenaed by the court, if the client poses a risk to themselves, if they disclose a risk to others, or if there is an omission of intent to commit a serious crime.
Yes, I understand that my information is kept confidential except the circumstances mentioned above.
Clinical Notes are kept by inTrance Therapy for a period of 7 years. They will only be released at the client's request or if subpoenaed by the Court.
Yes I am aware of the record-keeping requirements
The use of online technology such as Zoom Online Video Calls pose a risk to confidentiality. Although the risk is low if using online platforms to conduct online sessions, you are agreeing to the risk.
Yes, I agree the risk associated with confidentiality and ZoomNo, I disagree
I acknowledge that unless I give 24 hours’ notice of a session cancellation I may be charged in full.
Yes, I understand I need to give 24 hours’ notice not to incur fees
I have read and understood the information provided to me in this document and understand that any sessions with inTrance Therapy will be designed and structured on the information supplied in this intake form.
Yes, I understand
As a Mandatory Reporter inTrance Therapy is obliged by law to report to the authorities if there is a reasonable concern for the safety of the client or others, as well as being informed of an omission of intent to commit a serious crime
Yes, I understand the requirements of inTrance Therapy as a Mandatory Reporter.
In Hypnosis you will be in control and completely aware of your surroundings and what you take on board.
YesNo
Word of MouthGoogleDoctor's ReferralOther TherapistInstagramFacebookLinkedInOther
If other, please describe:
Would you like to keep in contact with inTrance Therapy to be kept informed of workshops, events, information updates that would support and reinforce the work you do in your session here at InTrance Therapy
Parent's/Guardian's Full Name
Today's date
I understand that by ticking this box constitutes a legal signature confirming that I have read this document and have provided true and factual information therein and agree to the terms for all therapies provided by inTrance Therapy and its qualified therapist.
Please make sure to submit your inTrance Therapy client intake form 72 hours before your session. It will ensure that your child will get the most out of their session time.
Thank you!
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