Client Intake Form

Client Details

Confidential

Thank you for your interest in working with me, the Game Changer Therapist. Please take a few moments to fill out this application form. Your responses will help me understand your needs and goals, and determine if we are a good fit to work together.

If you are taken on as a client the information you provide will become part of your confidential records. By completing and submitting this form online you hereby give your consent for us to collect and process the below information, as required by us, the therapist, for the pursuance of both our own and your legitimate interests. You have read, understood and You accept our Privacy Notice in respect of the handling of your recorded data. Privacy notice is available here- https://www.pargasims.com/privacy-policy/

Full Name*

Surname*

Date of Birth*

Date

Address House number/Name*

Address Street Name*

Address Town/City*

Address County/State

Address Postcode/Zip Code*

Address Country*

Home Telephone number

Area CodePhone Number

Mobile Telephone Number*

Email address*

example@example.com

Occupation*

Emergency contact Name*

Emergency Contact Mobile Telephone Number*

Emergency contact Relationship*

GP Surgery name and address*

GP Surgery Telephone Number*

How did you hear about me, The Game Changer Therapist?

Briefly describe your current situation/areas of concern and why you are seeking therapy/coaching.

Why is now the right time to make a change?

What are your goals and aspirations for personal growth and development?

What steps have you taken so far to address these challenges or work towards your goals?

On a scale of 1 to 10, how committed are you to making changes and taking action towards your goals?

Have you ever worked with a therapist or coach before? If yes, please provide details.

What do you hope to achieve by working with me, the Game Changer Therapist?

Is there anything else you would like me to know about you or your situation?

Are you willing to invest time, effort, and resources in yourself to create the changes you desire? Please note, my private 1:1 programs start at £1200.

YesNo

Have you ever had a diagnosis of Schizophrenia, Psychosis or Epilepsy?*

YesNo

If Yes to the above please give details

Are you currently taking any medication for help with mental health? Please give details.*

YesNo

If Yes to the above please give details

Does anyone in your family (blood relatives) suffer with any psychological problems*

YesNo

If Yes to the above please give details

Do you Smoke?*

YesNo

If yes, please give details how many, how often

Do you drink alcohol?*

YesNo

If yes, please give details how much, how often, any blackouts, etc.

Do you use any recreational drugs?*

YesNo

If yes, please give details what drugs, how often, last use etc.

Do you have a history of trauma (any kind of abuse, neglect, victim of natural or other disaster etc)?*

YesNo

If yes, please give details

Do you have any work/school-relatedproblems/relationship problems?*

YesNo

If yes, please give details

Do you have a history of trauma (any kind of abuse, neglect, victim of natural or other disaster etc)?*

YesNo

If yes, please give details

Symptoms checklist Please answer the questions below as honestly and accurately as possible

Sleep*

Appetite*

No problemsNo interestIncreased appetiteCarbohydrate craving

Energy*

NormalIncreasedLowUp and down

Interest in Sex*

NormalIncreasedLow

Concentration*

NormalSomewhat difficultPoorTerrible

Memory*

GoodSome difficulty rememberingPoor

Depressed or Sad*

All the timeMost daysSome daysNot at all

Suicidal Thoughts*

All the timeMost daysSome daysNot at all

Past Suicide Attempts*

YesNo

If yes to the above please give details

Anxiety*

All the timeMost daysSome daysNot at all

Panic Attacks*

FrequentlyOccasionallyNot at all

Anger/Irritation*

All the timeMost daysSome daysNot at all

Any other comments or information that you wish to share

Consent

I hereby give my permission for you to collect and process the above information, including any sensitive personal information as defined under the General Data Protection Act (GDPR), and as required by you, the therapist, for the pursuance of both my own and your legitimate interests. I have read, understood and I accept your Privacy Notice in respect of the handling of my recorded data.

I understand that the Hypnotherapy process practiced by Parga-Sims/Maxcebo Method is not a medical treatment and is not a substitute for allopathic medicine. I understand that I should continue any present medical treatment and consult my regular medical Doctor for treatment of any new or existing illnesses. I fully accept that no guarantee of a cure can be given for any presenting issue or any issues which may become apparent during therapy. The Hypnosis Treatment by Rachel Parga (Registered Clinical Hypnotherapist) is a process where am guided to use my own inner abilities for my own benefit. I give my permission to use varying Hypnotherapy and NLP techniques on me.

Fees for all online appointments must be paid upon booking, in advance, prior to the appointment(s) being confirmed. No appointment may be cancelled within 24 hrs of the booked appointment. Any fees paid will be forfeit as we cannot replace the booking. Any appointment that you wish to cancel with more than 24 hours' notice may be moved at no charge to another mutually available time slot. Once fees are paid there can be no refunds, unless the appointment is cancelled by us. In this case you are entitled to a refund.

These terms and conditions do not affect your statutory rights, which will always be respected. By using our services you accept that all services and courses are supplied and delivered from the UK and are subject to UK law and any UK regulations governing our services and treatments. Online sessions may be recorded (with your consent) for safeguarding purposes. These video files will be deleted within 4 months after the end of any course of treatment. You have the right to view these files (streamed) as part of your online treatment, in order to remind you of points raised during therapy. These files may not be downloaded or passed to any third party without written consent of all parties who appear in the video, other than where necessary as part of the GHR ethical code of conduct.

By submitting this application, you acknowledge that all information provided is accurate and true to the best of your knowledge. You also understand that filling out this form does not guarantee acceptance into any of my programs, and I reserve the right to decline any application.

Thank you for taking the time to complete this application. I will review your responses and be in touch with you shortly to discuss the next steps.

Rachel Parga

The Game Changer Therapist

Do you Consent to the above*

YesNo

Please sign inside the box*

Todays date*

Date

Please answer the following health questions: