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Client Intake Form

Online form or PDF.

Please complete the Client Intake Form as much as possible using the online form below within 48 hours of our first full session.

If you are having difficulty, please download the pdf form and complete and email to me at [email protected] within 48 hours of our first full session.

Download PDF
Client Intake Form

Client Information

Client Name
Client Name
First
Last
Gender
Marital Status

General and Mental Health Information

Permission to contact Doctor

Hypnotherapy

Therapy Outcomes

Basics Assessment

Behaviour

Affect

Sensations

Imagery

Ask the client to close their eyes and imagine they are doing the behaviour(s)).

Cognition

Self-Talk

In respect of the behaviour(s) you have described:

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