Strategic Psychotherapy & Clinical Hypnosis Client Intake Form

Strategic Psychotherapy & Clinical Hypnosis Client Consult Form

Private & Confidential
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Postal Code
What is your age?
What is your gender?
Email Address*
example@example.com
Contact Number*
Why would you like a Strategic Psychotherapy and Hypnosis appointment? Please comment here: blanks . Have you tried Hypnosis before? Please comment here: blank .
Are you currently taking any medication?*

YesNo
Please list them.
Do you have any medication allergies?

YesNoNot Sure
Please list them.
Are you a smoker?*
Do you use any kind of illegal drugs or have you ever used them?*
What kind of drugs? How long have you used/been using them?
Describe you alcohol consumption?*
DUTY OF CARE & SCOPE OF PRACTICE: Please note that Sheena has a duty of care and your safety is paramount. Right care in the Right Place for Quality Care. Please tick any of the conditions below which are relevant to your health currently.*

DepressionAnxietyChronic InsomniaPhobiasAddictionsCompulsive DisordersDrug AbuseEating DisordersSchizophreniaBipolar DisordersNone of the aboveOther
Do you suffer from any of the following?

Respiratory ProblemsDigestive IssuesHigh Blood PressureDizziness/FaintingBack or Neck PainPsoriasis/Skin ComplaintsNone of the above
What condition are you hoping resolve with Strategic Psychotherapy and Clinical Hypnosis?*

Generalised AnxietySocial AnxietyPerformance AnxietyRelationship StressWork StressDepressionTrauma/PTSDBehaviour ModificationAddictionsStudy Skills/MemoryPhobiasPainPost Operative HealingOther
Are you a member of a health fund?

YesNo
N.B Health fund rebates vary between funds and levels of cover. Additionally, changes in policies can occur at any time. We cannot tell you if your particular insurance policy will your cover hypnotherapy sessions, or what your rebate will be.

I agreeI disagree
How did you find out about Sheena's Healing Hands and Clinical Hypnosis

TelevisionDoctor's ReferralGoogleNatural Therapy PagesFriendOther
Would you like to be kept informed of workshops that would support and reinforce the work you have done here in the clinic

YesNo
Would you be willing to answer a short questionnaire following your completion of your treatment plan a few months after completion for future research and quality improvement purposes?

YesNo
The Treatments for Strategic Psychotherapy & Clinical Hypnosis can be carried out via in person or Zoom meetings. Please select your preference.*

In Person TreatmentsZoom Meeting
PAYMENT POLICY: I acknowledge that I will pay the full investment prior to the first session as quoted by Sheena. Taking this step is essential to ensure that I am fully committed to the treatment plan. In addition, it is imperative that I complete the tasks identified and necessary for my success with the treatment plan.*

I AgreeI Disagree
INFORMED CONSENT: I give consent to the use of hypnosis as a treatment tool during my Strategic Psychotherapy & Clinical Hypnosis?*

YesNo
CANCELLATION POLICY: I agree, I may be charged in full unless I give 24 hours notice of the session cancellation.*

I AgreeI Disagree
DISCLOSURE: My understanding is that if I disclose to Sheena that I have or intend to commit any criminal acts, including self-harm, child abuse or harming others, Sheena is a MANDATORY REPORTER and is legally obligated to report these actions or intentions to the relevant authorities; after speaking with me first.*

I AgreeI Disagree
DISCLAIMER: I declare that the above information is true and correct and indemnify Sheena's Healing Hands of any liability for any false or misleading statements given. I understand and accept that nay treatment received. I also recognised that I am seeking alternative/non-medical treatment that may not be supported or endorsed by established medical practice. Sheena's Healing Hands is a remedial therapeutic nature and not of a diagnostic/curative approach. I also understand and accept that the results of my treatment are not guaranteed in any way and that any data or notes taken during the sessions will remain the property of Sheena's Healing Hands as part of the case history records. In addition, I am attending the clinic of my own free will and consent and exercise my right to discuss and choose any suitable treatments available to me.*

I agreeI disagree
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Print Name*
Signature*
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CONFIDENTIALITY AND PRIVACY: All documentation and data is kept secure at Sheena's Healing Hands and your Confidentiality and Privacy is paramount for any care received.
Sheena will contact you shortly in the next 48 hours to offer you a free 15 minute consultation. Sheena will discuss the potential investment costs required to make positive changes in your life. Sheena will also ensure you understand the commitment that is required for success with Strategic Psychotherapy and Clinical Hypnosis.
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Strategic Psychotherapy & Clinical Hypnosis Client Consult Form

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CONFIDENTIALITY AND PRIVACY: All documentation and data is kept secure at Sheena's Healing Hands and your Confidentiality and Privacy is paramount for any care received.