CONFIDENTIAL INTAKE FORM

First Name

Email Address

Last Name

Date of Birth

Address

Phone

Emergency Contact Person’s Name and Contact Number and Relationship to Client

Occupation

Name of Partner (Or Parent If Under 18)

Name Of Family Doctor

Number of Children

Please list all current medicines and supplements that you are taking

Please list all physical and psychological issues that are affecting you at the moment

Do you smoke? If YES, How many a day? Do you want to give up?

Do you consume alcohol? If YES, How much per week?

Would you like assistance to reduce your consumption of alcohol/other drugs?

Have you ever used illicit drugs? Please give details

Religion/Life Philosophy

How did you hear about this Clinic?

Have you ever had Counselling or Clinical Hypnotherapy before? If YES, Name of Counsellor/Clinical Hypnotherapist: Issue(s) treated Treatment Period

What is your major goal for your appointments?

Payment Policy

I agree to the terms & conditions

Select a date

Provision of Consent

I agree to the terms & conditions

Select a date

Thank you for submitting.