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Initial Session Registration Form

Registration Details - Adults:
  * required field
Name: *
Gender:
Age:
Mobile Phone: *
Email: *
Email confirm: *
Address:
Occupation:
Marital Status:
Children Ages:
Smoker?:
Alcohol Consumption?:
Medications:
Asthma:
Have you ever been diagnosed
with any mental health issues
(eg. Schizophrenia, Psychosis,
Clinical Depression, Bi-polar
Disorder, etc)?
Previous hypnotherapy?
How well do you sleep?:
Do you use sleeping tablets?:
Do you exercise regularly?:
Please state the nature
of the issue in your
own words:
Using a scale of 0 to 10 – with 0 being never and 10 being very much, please indicate next to each feeling how this is for you:
Scared Anxious Insecure
Panicky Overwhelmed Frustrated
Resentful Angry Rage
Envious Jealous Sad
Disappointed Hurt Shocked
Numb Guilty Ashamed
Embarrassed Humiliated Worry
Calm Content Excited
Proud Acceptance Belonging
Happy Other  
YOUR DESIRED OUTCOME FOR THERAPY:
(How would you like to feel/behave/see yourself at the end of successful therapy?
What would you like to achieve?)
After therapy I offer a free follow up. What is your preferred method of follow up/feedback?
How did you find me?
Private Health Fund?:
Can I add you to my mailing
list for updates?
 
Terms and Conditions
Please read carefully
 
1.In order to gain the most benefit from therapy it is the client's responsibility to participate to their best ability, which includes undertaking work at home, such as visualization and relaxation practice. Succeeding in doing so remarkably increases the chances of therapeutic success.
2.Hypnotherapy may be unsuitable as a therapy for clients with certain mental health conditions such as schizophrenia and bi-polar disorder. Clients with such conditions must discuss it with the therapist PRIOR to any therapy.
3.There is no charge for late cancellations, we work on the basis of mutual respect, please give at least 24 hours notice for any changes in a scheduled appointment.
4.Please come to sessions at the scheduled time and not earlier, since another client might still be in session, or the therapist is on a short break.
5.I consent to Therapy by hypnotherapy and NLP with Yael Reiss and understand that this therapy should never be used as a substitute for medical treatment.
6.No guarantees are offered.
I have read and understand the above Terms and Conditions.
 


Brighton QLD
North Brisbane
07 3869 0469
0431 83 7878
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Registration Form (Adults)

Registration Form (Children)