NEW CLIENT INTAKE FORM

 

For Client's of Freedom from Food, to be Completed Prior to First Appointment

If you have booked in for a first session for hypnotherapy and/or counselling, you will be required to fill out this form. Please fill this out to the best of your ability and if you have any questions, please get in touch via email at bianca@freedomfromfood.com.au or by phone on 0422014782. If you would prefer to fill out and return a PDF of this form, please also get in touch prior to your appointment and a PDF will be sent to you as an alternative.

Name*:
Pronouns:
Email*:
Phone*:
Address*:
Date of Birth:
Occupation:
Religion:
Next of kin, relationship to them & contact number:
Doctor/GP's name and name of clinic:
Permission to inform doctor of your treatment?:
How did you hear about Freedom from Food?:
Have you ever suffered from any of these? Place a tick next to all that apply:
In the last 12 months, have you seen a counsellor, psychiatrist or psychologist?:
In the last 12 months, have you seen a dietitian, nutritionist or any other complementary health provider?:
If you have a treatment team, would you like me to maintain contact with any of these practitioners? (Note that in cases deemed a significant medical risk, this may be a requirement to undergoing counselling/hypnotherapy). If so, what are their contact details?:
Do you/have you had any recent/present medical conditions, hospitalisations or surgeries? Details:
Please list any current medications:
Smoker:
If yes, how often/how much?:
Alcohol:
If yes, how often/how much?:
Caffeine:
If yes, how often/how much?:
Illicit Drugs:
If yes, how often/how much?:
Exercise:
If yes, how often/how much?:
Have you ever been hypnotised/studies yoga/meditated? If so, details?:
Any other relevant information?:
I declare that the above information is true and correct. I understand that all of the information that I provide is held in the strictest confidence. I also understand that individual results may vary, and that hypnotherapy, the same as any form of therapy, comes with no guarantee. I request hypnotherapy if deemed appropriate.
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Data Collection, Processing, and Privacy Statement

Thank you for entrusting Freedom from Food with your personal information. Please be assured that the information collected in this form is treated as confidential and will strictly only be used for the intended purpose of engaging with therapy. This information will never be sold or passed on to third parties. Personal information entered into this form will not be stored on the website but, in a secure location that only Freedom from Food will have access to. Completion of this form implies consent for Freedom from Food to use this information for the purposes of therapy and securely store your data. Information obtained during the course of therapy is required by law to be kept for seven years, after which point, records will be destroyed.

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I would like to acknowledge the Wurundjeri people who are the Traditional Custodians of this land upon which Freedom from Food operates. I would also like to pay respect to the Elders both past and present of the Kulin Nation and extend that respect to other Indigenous Australians, past, and present.


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