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Client Intake Form
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For Solution-oriented therapy. Call 0447 104 745

Home
Working with Alma
Extras
Client Intake Form
Lets Chat

Client Intake Form

Name *

DOB

Sex

Landline

Email *

Address

Employment

Marriage Status

Previous Hypnosis

Reason and expected outcome for this visit:

Are you currently under a physician’s care?

Name of Provider:

Ongoing Treatment:

Current Medications:

Do you currently see a therapist?

Name of Therapist:

Treatments:

Effective?

HYPNOSIS TARGET

Smoking
Nail - Biting
Weight Loss
Relationship
Stress
Anger
Motivation
Anxiety / Fear
PSTD
Other

Health fund rebates vary between funds and levels of cover. Please check with your health provider to see if you are covered.

Agree
Disagree

How did you find me?

Dr’s Referral
Other Therapists
Google
Other

Cancellation policy: I acknowledge that unless I give 48 hours notice of a session cancellation, may be charged in full for that session.

I Agree
I Disagree

I also recognise that I am seeking alternative /non-medical treatment that may not be supported by establishing a medical practice.

I Agree
I Disagree

Full Name Confirmation

Date

Phone

Let's get in touch

Send me an email and I'll get back to you, as soon as possible.

Alma Martin

Clinical Hypnotherapy & Strategic Psychotherapy Practitioner, Neuro-Linguistic Programming Master Practitioner, NLP Strategic Coaching Certificate, Bachelor of Psychological Science, Post Graduate Diploma of Psychology (Advance), Time Line Therapy.

FIND US AT THE OFFICE

Alma Martin

Tamworth

Contact Info

0447 104 745
info@hypnotherapytamworth.com.au
https://tamworthhypnotherapy.com.au

Office Hours

Saturday

8:30am-12:00pm

Due to the threat of contracting Coronavirus and clients wished to reduce the danger of infestation, I have decided to offer online sessions only for the time being.

© 2024 · Institute of Applied Psychology IAP

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