Client Intake Form

EVOLVED COUNSELLING& HYPNOTHERAPY

UNDERSTAND YOURSELF - FIND YOUR BALANCE - LIVE YOUR LIFE

To be completed and returned prior to your first session

Please provide the following information for our records. Leave blank any questions you do not want to answer, or would prefer to discuss with me privately.
Information provided here is held to the same standards of confidentiality as our therapy.

client intake form

Name *

Name of Parent/Guardian (if under 18) *

Address *

Phone Number *

Email *

Emergency contact name

Emergency contact telephone number

Gender *

Female

Male

Other

Marital Status *

Never Married

Domestic Partnership

Separated

Married

Divorced

Widowed

Age *

Less than 13

13-18

19-25

26-35

36-50

Over 50

Prefer not to say

Have you previously received any type of hypnotherapy or mental health services?

Yes

Have you had a previous Mental illness/ Diagnosis ?

Yes

Is there a history of mental illness in your family ?

Yes

Are you currently taking any prescription medication ?

Yes

If yes, what medication are you currently taking?

GP name/details ?

Do you have any concerns about any of our services?

What would you like to accomplish from treatment?

Do you believe that you can fit treatment into your schedule?

Yes

Maybe

Please list any specific sleep issues you are currently experiencing.

What types of exercise do you participate in?

Are you currently experiencing overwhelming sadness, grief, or depression?

Yes

Maybe

Are you currently experiencing anxiety, panic attacks or have any phobias?

Yes

Maybe

Do you think about hurting yourself or have any suicidal thoughts? *

Yes

Maybe

Do you think about hurting others? *

Yes

Maybe

Are you currently experiencing any chronic pain?

Yes

Maybe

Do you drink alcohol more than once a week ?

Yes

Do you engage in recreational drug use?

Daily

Weekly

Monthly

Infrequently

Never

Do you have any problems eating or with your appetite?

Yes

Are you currently in a relationship?

Yes

Maybe

If yes, how would you rate your relationship? 1 bad to 5 excellent

What significant life changes or stressful events have you experienced lately ?

Are you currently employed?

Yes

Do you enjoy your work ? Is there anything stressful about your work?

Do you consider yourself to be spiritual or religious ?

Yes

Other

Everything discussed will remain private and confidential unless subpoenaed by the courts, or if it appears that you have the intent to cause harm to yourself or others. Do you understand and agree? *

Yes

Notes will be taken during the session and digitally recorded to your personal chart. This is private and confidential, and will not be shared with third parties unless you have given written consent or has been, subpoenaed by the courts. Do you understand and agree ? *

Yes

Cancellation or resheduling within 48 hours of your appointment may incur a 50% cancellation fee. Cancellation within 24 hours or not showing up for your appointment may require full payment. Providing sufficient notice of cancellation enables another client to make use of session times. This will be reasonably assessed, understanding of illness and unforseen circumstances will be applied and fee may be waved. Do you understand and agree? *

Yes

Signature - I declare this information is true and correct. *