Confidential Intake Form

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Filling in this form prior to your initial consultation will mean that there will be more time for you to enjoy your session. It will take around 30 minutes to complete and please answer as best you can. Some questions may seem irrelevant at the time, but you can be assured that they will help to make your session as individual as you are.
Not everyone is suitable for Hypnosis.
Clients suffering from diagnosed mental disorders such as schizophrenia and bipolar may not be suitable for hypnosis. In some cases it may be necessary to get a referral or written approval from your GP or Health Care Professional.

Hypnosis is a powerful tool to help you achieve your goals and bring about rapid change. During Hypnosis you will be in a very relaxed state, however you will be fully aware of everything at all times Hypnosis allows suggestions to your subconscious mind to make these changes more effective. You cannot be made to anything that is against your will.

Hypnotherapists with membership of an accredited association such as the Australian Association of Clinical Hypnotherapists and Psychotherapists work with a code of conduct and all information gathered is private and confidential, complying with the Privacy Act.
Please do your best to be punctual. If you are unable to make your appointment please let me know two business days in advance to enable us to fill your spot - appointments broken or cancelled without this notice may be charged for the session. You will need to pre-pay your next session before the next appointment is accepted.

Email *

Name *

Email *

Address *

Phone number *

Date of Birth *

YYYY

Place of Birth (City/town)

What’s not working? *

How long has it been a problem? *

Have you had other treatments for this, and if so, with whom and for how long/when? *

Are you on prescribed medication for this, and if so, what, dose, and for how long? *

How would you know you have achieved a satisfactory result? What would be different? *

List 3 favourite colours *

List 3 favourite places *

List any current health problems including any medications: *

List 3 of your most important life goals *

List 3 of your hobbies/favourite pastimes *

Are you currently suffering from any of the following? Tick all that apply *

Nervousness

Inability to relax

sleeplessness

Nail biting

Compulsive tendencies

nightmares

Overeating

Substance abuse (alcohol, cigarettes, prescription or non prescription drugs)

Inability to focus attention

Teeth grinding

Lack of energy

Fear of heights

Poor self esteem

Childhood trauma

Lack of success

Other:

Required

RELEASE STATEMENT: I understand that Meg Phillips is a Clinical Hypnotherapist & Coach and is not a medical practitioner or psychologist. Hypnosis, also referred to as Hypnotherapy, can be used as complementary care for a number of conditions but is not a replacement for a family doctor’s care, nor is it to be used as a replacement for any medications, diagnosis or treatment from a qualified Doctor. I hereby authorize Meg Phillips to hypnotize me for the concerns that we have discussed and/or that I have indicated on this intake form. The form is confidential and is used only as a tool to develop an effective tool for my individual needs. I give Meg Phillips permission to use hypnosis for any issues that may have been outlined on this form and for any future purposes that I might request. Please write your name below to confirm that you have read this statement. *

A copy of your responses will be emailed to the address you provided.

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