• Client Intake Form (approx 15 min to complete)

    Complete and return at least 2 days before your appointment. Completed forms are encrypted for your privacy and protection, however, only complete what you're comfortable with. We can go through the blanks when we meet.

  • Health Check

  • Have you ever suffered from any of the following?
  • Do you suffer from any of the following?
  • What are you looking at addressing through Hypnotherapy?
  • What type of Anxiety?
  • What type of Stress?
  • MEDICAL DISCLOSURE. 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 physical but a psychosomatic issue, or alternatively, it is a physical issue but there is nothing more the medical system can do for me.*

  • Lifestyle Check

  • Describe your alcohol intake
  • Describe your daily water intake
  • Describe your caffeine intake (including coke etc.)
  • Describe your quality of sleep

  • Wellness Check

  • Assess each point by rating your satisfaction on a scale of 1 to 10. 1 being room for improvement, and 10 being the most content.

    This will help us work on goal setting and points of focus.

    Remember - there's no right or wrong answer. You can interpret these points any way you choose

  •

  • How did you find out about us?

  • How did you find out about the Road?*
  • Would you like to be kept informed of workshops that would support and reinforce the work you have done here in the clinic?*
  • Would you be willing to answer a short questionnaire sometime in the future for research purposes?*

  • Confidentiality and Consent

  • CONFIDENTIALITY

    Your sessions with me are all completely confidential.

    There are situations where, if they present, I will be required to break that confidentiality.

    You need to be aware of these instances and acknowledge that you are aware of this.

    Instances where confidentiality will need to be broken:

    • There is the possibility of harm to yourself and/or others
    • I am required by law (subpoena or for mandatory reporting)
    • For purposes of referral and/or supervision
  • I also recognise that the therapist 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 practices*
  • I agree to the use of hypnosis as a treatment tool during my clinical hypnosis session and consent to this part of the session being recorded for my (the client) use only*
  • Further, I understand that clinical hypnotherapy is complimentary and NOT a cure or replacement for standard of care treatment of physical medical conditions and I will continue to follow my doctors advice.*
  • I understand that as part of my treatment plan, I may be asked to complete simple tasks in between sessions such as listening back to the recording or going for a walk. If I don't complete the tasks, my therapist may refuse to proceed with the subsequent session/s as these tasks are an important part of the process*
  • Please ensure you have adequate funds on your credit/debit card or cash for the first session.*
  • Are you a member of a health fund?*

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

  • I agree with the above statement
  • I acknowledge and consent that AI-assisted dictation tools may be used for the purpose of clinical note-taking and record-keeping. These tools are employed in a secure manner, used solely for documentation, and are not shared outside my confidential client file*
  • Cancellation Policy: I acknowledge that unless I give 24 hours’ notice of a session cancellation, I may be charged in full.*
  • Today's date*
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