Please enable JavaScript in your browser to complete this form.Client Name *FirstLastAge *Email *Mobile number (incl country code if outside Australia) *AddressHow did you hear about me?Please indicate any psychological conditions *Alcohol or Drug PsychosisSchizophreniaBipolarSenilityEpilepsySuicidal TendenciesHeart ConditionsOther (please describe below)Pathological PersonalitiesNot ApplicableDetails of any other psychological or chronic mental conditionsIf you have psychological conditions, do you have a referral from your medical practitioner for hypnotherapy?YesNoNot ApplicableAre you on any medication? If so, please list belowEmergency Contact Name *FirstLastEmergency Contact Phone Number (incl country code if outside Australia) *Have you had hypnotherapy before?YesNoIf "yes" how was your experience, what did you like/ dislike?Hypnosis Session PreferenceIn personOnlineWhat issue(s) would you like some help with?How long have you had this issue?Have you had any help in the past for these issues, was it helpful? Rate you issue out of 10 (10 being the most severe) Selected Value: 0 Why do you want help to change now?What changes do you want to see? What would be different about you and your life, how would that make you feel? Who and/or what is important in your life?Is there anything else you'd like to share?Any other questions?WAIVER OF LIABILITY: The above named client voluntarily agrees by their own free will and desire to be the subject of a Hypnotherapy session and accepts full responsibility for any and all injury arising from the Hypnotherapy session. The client shall hold harmless all parties involved in the Hypnotherapy session. *I have read and accept these termsNoSOUND MENTAL HEALTH ACKNOWLEDGEMENT: The client has been asked and is fully aware that they have disclosed to the practitioner any mental health issues they may presently have and/or any pharmaceutical medications or other professional treatments they have used in the past or are presently using. *I have read and accept these termsNoDISCLAIMER THE CLIENT UNDERSTANDS THAT THE HYPNOTHERAPIST IS NEITHER A TRAINED PSYCHOLOGIST NOR A MEDICAL DOCTOR At no time will the Hypnotherapist attempt to provide medical or mental health therapy. The client affirms that hypnotherapy is appropriate for them and does not conflict with existing medical or psychiatric treatment. Always follow the advice of your physician or other professional medical practitioner. *I have read and accept these termsNoWARRANTY: The Client understands and agree no warranty is given, expressed or implied, for satisfactory results from the Hypnotherapy session. *I have read and accept these termsNoMETHODS USED: The Client understands the hypnotherapist employs hypnosis, mesmerism and relaxation techniques and/or a combination of these methods to facilitate the client’s quest for self-improvement. Specific techniques may include body relaxation, directed meditation, age and past life regression, NLP and other behaviour modification techniques. *I have read and accept these termsNoBy clicking 'I agree,' you acknowledge that you have read and understood the MindTonic Privacy Policy available on this website, which details how we collect, use, and protect your personal information in line with Victorian privacy laws. We will only use your data to provide you with our services, and we will not share it with third parties without your consent. *I agreeI do not agreeFull Name and Date (DD/MM/YYYY) *Submit
