Are you currently taking any medication?

If yes, what is it and why was it prescribed?

Are you currently under the care of another therapist?

Have you had hypnotherapy before?

Are you a smoker?

Describe your alcohol consumption

Describe your quality of sleep

Have you ever suffered from any of the following?

What is it that you expect we can help you with?

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.

How did you find out about the clinic ?

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?

Cancellation Policy: I acknowledge that I, unless I give 24 hours notice of a session cancellation, may be charged in full.

Disclosure: I understand that if I disclose that I have or intend to commit certain criminal offenses, the Therapist is obliged by law to report me to the authorities.

I also recognise that I am seeking alternative/non medical treatment that may not be supported or endorsed by established medical practice. 

Please use this space to provide any other information you feel may be relevant.