Online Intake Form
Date of Birth
Address Line 1
Address Line 2
State / Province / Region
Antigua and Barbuda
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Cocos (Keeling) Islands
Congo (Democratic Republic of the)
Eswatini (Kingdom of)
Falkland Islands (Malvinas)
French Southern Territories
Heard Island and McDonald Islands
Iran (Islamic Republic of)
Ireland (Republic of)
Isle of Man
Korea (Democratic People's Republic of)
Korea (Republic of)
Lao People's Democratic Republic
Micronesia (Federated States of)
Moldova (Republic of)
North Macedonia (Republic of)
Northern Mariana Islands
Palestine (State of)
Papua New Guinea
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Sint Maarten (Dutch part)
South Georgia and the South Sandwich Islands
Svalbard and Jan Mayen
Syrian Arab Republic
Taiwan, Province of China
Tanzania (United Republic of)
Trinidad and Tobago
Turks and Caicos Islands
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Vatican City State
Venezuela (Bolivarian Republic of)
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
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?
Describe your alcohol consumption:
I don't drink at all
A glass or two at night
I use it to help me sleep
Describe your quality of sleep
Have you ever suffered from any of the following?
Non of the above
Do you suffer from any of the following?
Back or neck pain
High blood pressure
Non of the above
What is it that you expect we can help you with?
Confidence / Self Esteem
How did you find out about the clinic?
Natural Therapy Pages
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 like to subscribe to free monthly hypnosis downloads?
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, I 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 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 established medical
I understand that any audio provided contains powerful hypnotic suggestions. I therefore will not listen to any MP3 recordings whilst driving or operating machinery.
I have read the Terms and Conditions and agree
Missed appointments or appointments which are rescheduled with less than 48 hrs notice are chargeable at the full fee. This is further clarified at our initial meeting and is a minimum requirement to ensure fairness to other clients who may need that appointment. Exceptions can be made in the case of any emergencies of genuine sudden illness. Appointments need to be kept to make the necessary progress with your recovery. Most sessions are for one hour any lateness cannot be accommodated by adding additional time to the end of the sessions due to the impact on other clients. Think Hypnotic Solutions may also ask your permission to hold credit or debit card details on file in case of missed appointments. They are confidential and not shared with any third parties. We do not use the details, unless you don’t turn up or contact us. This is discussed at the initial consultation. For all appointments we take payment a week in advance each week. Initial Consultations Initial Consultations may take between 60 to 90 minutes in a professional and confidential environment to discuss your medical history and your expectoration with hypnotherapy. Depending on your requirement, your sessions may include up to 4 to 5 session. Subsequent sessions can be purchased with an added discount. Your initial consultation will also help determine whether hypnotherapy is the best course of action for you without any obligate or commitment to continue.
I have read the disclaimer
PLEASE READ CAREFULLY BEFORE USING THIS SITE. This site does not provide medical advice. The content is for informational purposes only. Consult with your Doctor (GP) on all medical issues regarding your condition and its treatment. The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. It is not a substitute for a medical exam, nor does it replace the need for services provided by medical professional. Always seek the advice of your medical professional before making any changes to your treatment. Any medical questions should be directed to your personal doctor. Expectations of therapy: Each individual responds differently so we plan and tailor your therapy to best match your needs, individual requirements and personality type. We use a multi-modal approach to therapy based upon your individual needs. There are no guarantees that any of these courses of action will solve your issues. It is our intention to help you to help yourself, by facilitating a deep awareness of what is actually troubling you and helping you to empower yourself to make the appropriate changes. We can make no promises that we can help you, however, we can promise to do our best to help you. What you are paying for is our professional time and not necessarily a cure. We will ask you to do homework in between sessions and it is up to you to undertake these tasks in order to gain positive benefit and progression in your treatment and recovery. It is our experience that hypnotherapy and its approach can provide many beneficial effects; however, hypnosis does not substitute proper medical attention. Any material or information detailed on this site or on any merchandise is not intended to diagnose, treat, cure or protect against any disease or illness, always seek advice of a qualified doctor. Hypnotherapy downloads are not recommended for persons experiencing mental disorders or illness. Never listen to or play hypnosis tracks or audio whilst driving or operating equipment, always select an environment that is safe and secure. The audio products have been developed to assist you and give no guarantee; you yourself can be the only person that can provide a guarantee for your own success.
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
Do you consent to the use of hypnosis as a treatment tool during your clinical hypnosis
Please use this space to provide any other information you feel may be relevant
0423 810 056
6 Mitti Street
Blacksmiths NSW 2281
How can we help?
Stress and Anxiety
Client Intake Form
Terms and Conditions
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