CLIENT INTAKE FORM Please complete the following form prior to your initial appointment. General InformationMedical InformationLifestyle InformationPresenting IssueHypnotherapyConsent Consent to leave message/text YesNo Next Are you currently under the care of a psychiatrist, psychologist or counsellor? YesNo BackNext Do you consider you eat a healthy diet? YesNo Do you smoke? YesNoTrying to Quit Any recreational drug use? YesNo BackNext Are you currently having or have had in the past any medical or psychological treatment for this issue? YesNo BackNext Have you ever had hypnotherapy before? YesNo BackNext CONSENT By submitting this form I confirm that I am willing to be guided through hypnosis for the purposes of self-improvement. I understand that the hypnotherapy I am receiving is not a substitute for normal medical care. I should continue any present medical treatment and consult my regular medical doctor for treatment of new or existing illness. I accept that no guarantee of a cure can be given for any presenting issue or any issues that become apparent during the course of therapy. I also agree to the following TERMS AND CONDITIONS: APPOINTMENTS If you are running late for an appointment please contact me as soon as possible. Unfortunately a full session cannot be guaranteed if you are late but I will try to accommodate you if possible. Failure to attend an appointment without notification will result in full payment of the session being due. Where the session has been prepaid there will be no refund. CANCELLATIONS If it is necessary for you to cancel or reschedule and appointment please give 24 hours’ notice so that the appointment can be offered to another client. If you give less that 24 hours' notice the full fee for that session will be charged.
