TranceForm Your Life. Call (02) 9543 4433.
Full Name
Date of Birth
Preferred Contact Number
Email (must be completed)
Address
Emergency Contact Name
Emergency Contact Number
Are you working? YesNo
What kind of work do you do?
Hobbies
1. Are you currently taking medication? YesNo
If yes, what is it and why was it prescribed?
2. Are you currently under the care of a Medical Practitioner and/or Therapist? YesNo
If yes, please state the nature of the care they provide to you:
3. Have you ever been diagnosed with a mental illness? YesNo
If yes, please describe
4. Has anybody in your family ever been diagnosed with a mental illness? YesNo
5. Have you ever had Hypnotherapy before? YesNo
If yes, please describe your experience and outcome with Hypnosis:
6. What are you expecting we can help you with? Please tick, more than one answer possible. AnxietySocial AnxietyPerformance AnxietyStressProcrastination/MotivationMild DepressionPhobiaTrauma/PTSDCessation of DrinkingCessation of Binge eatingCessation of SmokingOCDChronic PainOther, please describe below
Other, please describe below:
7. Do you smoke? YesNo
If yes, how many cigarettes do you smoke in a day:
8. Describe your alcohol consumption? I don't drink at allSociallyOccasional bingesA glass or two at nightI use it to help me sleepMore than 10 drinks a week
9. Describe your sleep GoodVariableAveragePoor
If you have issues with sleep, please describe them below:
10. Have you ever suffered from any of the following: DepressionAnxietySocial AnxietyPhobiasChronic InsomniaAnger ManagementEating DisordersAddictionsCompulsive DisordersChronic PainBipolar DisordersSchizopreniaPersonality DisorderOther diagnosedNone of the above
If other, please provide details:
11. Do you suffer from any of the following: Respiratory ProblemsDizziness/FaintnessDigestive IssuesBack or Neck PainHigh Blood PressureLow Blood PressurePsoriasis/Skin ConditionsNone of the above
If you suffer from other conditions you believe I should know about, please describe below:
12. How is your general physical health? GoodAveragePoor
13. How is your mental health? GoodAveragePoor
14. How is your emotional health? GoodAveragePoor
Please list, if any, your allergies:
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 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 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 I am currently under the care of, aware that I am 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 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 poses 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
Today's date
I understand that 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.
By law, if you are under 18 years, consent from your parent or legal guardian is required. Please tick below if you are under 18 years and get your parents or guardian to complete the Under-18 Client Intake Form.
Yes, I am under 18 years and I will get my parent or guardian to complete the Under-18 Client Intake Form
Please make sure to submit your inTrance Therapy client intake form 72 hours before your session. It will ensure that you get the most out of your session time.
Thank you!
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