For all new patients: Please complete this form before first appointment. Thank you. Name*: Phone*: Consent to leave message/SMS: YesNo Email*: Street Address: Suburb: State: NSWVICQLDSAWATASNTACTOther Postcode: Date of Birth: Age*: Gender: MaleFemale Marital Status: Children: Occupation: Medical Information Significant medical conditions: (please list) Current medications: (please list) Are you currently under the care of any psychiatrist, psychologist or counselor? YesNo If yes for what and how long have you been seeing your therapist: Lifestyle Information On average how often do you exercise per week? (e.g. walking, swimming, cycling, running, gym, yoga) ---4 or more times2-3 times1-2 timesless frequentlyI currently don’t exercise On average your sleep is: ---GoodAveragePoorDifficulty getting to sleepDifficulty staying asleep On average I eat a healthy diet: ---SometimesMost of the timeAlwaysOn weekdaysOn weekendsI don’t think my diet is healthyI would like to make healthier choices On average how would you describe your alcohol consumption: ---Non-drinkerSocial drinkerRegular drinkerDaily drinkerBinge drinkerI would like to drink lessI would like to quit Do you smoke? YesNoTrying to quit Hobbies and Interests: Presenting Issue* I would like help with: How long has this problem existed? Are you currently having (or in the past had) medical or psychological treatment for this presenting issue? YesNo If yes please give details: Hypnotherapy Have you ever had hypnotherapy before? YesNo If yes for what and what results did you experience: Do you have any questions about hypnosis? How did you hear about Hypnotherapy Solutions? Word of MouthGoogle/InternetOther (please specify below) Other: CONSENT By submitting this form I confirm that I am willing to be guided through hypnosis for the purposes of self improvement. I understand that the hypnotherapy I am receiving is not a substitute for normal medical care. I should continue any present medical treatment and consult my regular medical doctor for treatment of any new or existing illnesses. I accept that no guarantee of a cure can be given for any presenting issue or any issues which may become apparent during the course of therapy. I also agree to the following TERMS AND CONDITIONS. APPOINTMENTS If you are running late for an appointment please contact the office as soon as possible. Unfortunately a full session cannot be guaranteed if you are late but we will try to accommodate you if possible. Failure to attend an appointment without notification will result in full payment of the session being due. Where the session has been prepaid there will be no refund. CANCELLATIONS If it is necessary for you to cancel or reschedule an appointment please give 24 hour notice so that the appointment can be offered to another client. If you give less than 24 hour notice the full fee for that session will be charged.