Confidential Client History Form

Everything said in sessions of therapy is private and confidential, unless you (client) indicate or I the therapist believes that you have serious intent to cause harm to yourself or someone else.

Your therapist is a mandatory reporter, if in their clinical opinion they feel you may be at risk to yourself or others, they have a duty of care to report.

First Name

Last Name

Phone Number

Address

Date of Birth

Marital Status

Do you have any Children?

Yes No

Occupation

Spouse Occupation

Reason for Consultation?

Health Fund?

Personal Medical History

Current Medication

Previous Medication

Have you ever experienced anxiety?

Yes Not

If yes to previous question, how severe?

Known allergies?

Brief Family History

Did either of your parents have unrealistic expectations of you?

Any history of depression in your family?

Yes No Not Sure

If yes to previous question, how does it impact you?

Conscious Memory of past trauma’s?

Religion past and present?

What is your belief system?

Do you sleep well?

Do you socialize?

Do you have previous experience of Hypnotherapy?

Yes No

How do you relax?

What do you prefer for relaxation?

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