Contact Mindful Impact

First Name

Last Name

Postal Address

City

State

Postcode

Country

Email Address

Mobile Number (include Country code if outside Australia)

Occupation

Date of Birth

Age

Gender

Female
Male
Do not wish to disclose

How did you hear about Mindful Impact?

Client or Physician Referral - their name

Are you currently suffering from any of the following (tick all that apply):

Stress/Anxiety/Depression
Inability to relax
Sleeplessness
Sexual challenges
Alcohol or drug abuse
Nightmares
General poor health
Smoking
Compulsive behaviour
Fear of being seen/heard/judged
Weight management problems
Inability to focus
Poor memory
Marital/Relationship Problems
Recent divorce
War trauma/PTSD
Current illness
Death of a loved one
Childhood difficulties
Phobias/Fears
Lack of energy
Lack of success

How long have you had this issue/problem/symptom?

What is your priority goal during our time together?

Are you ready to make the changes necessary to address this goal?

Do you have a primary care physician?

Yes
No

Doctor's full name

Name of medical practice

Address of Practice

City

State

Postcode

Practice Phone Number

List any current health matters of concern:

List any medications you are taking:

Please briefly share anything else that would be helpful to know about you, (i.e., recent life-changing events such as deaths, divorce, job changes, health issues, past trauma etc.):

List any other matters that are negatively influencing you:

List your three favourite places to be (e.g. beach, forest, snow, city etc.):

When on holiday do you prefer relaxation or excitement?

What is currently your most important life goal?

User Agreement

By continuing you agree to the following:

FEES & PAYMENT: Payment is due in full prior to your appointment by EFT or credit card.

CANCELLATION POLICY: Your time slot is reserved exclusively for you. Please arrive promptly to obtain your full session. A 24-hour cancellation notice is required, except in an emergency. If you must cancel or reschedule due to an emergency, please notify us as soon as possible. In the event that you do not arrive for your session and proper prior notice has not been made, you will be charged the entire fee for the session. Thank you for your consideration.

PREPAID SESSIONS: The above Cancellation Policy also applies to any programs with prepaid sessions. Failure to keep your appointment or non-emergency short-notice cancellations will result in the forfeiture of a prepaid session. No refunds will be given for unused prepaid sessions. All prepaid sessions are non-transferrable and will expire after six months.

CONFIDENTIALITY: We will not release any client information to anyone without a written authorisation from you, except as provided for by law. 

MINORS: Appointments for children under age 18 require written consent from the parent or guardian. For optimum results, it is recommended that parents/guardians not accompany children in the session.

SAFETY: Sessions may be video recorded for client and practitioner safety. These recordings are kept confidential and are securely filed.

MEDICAL HYPNOSIS: Hypnosis is effective in relieving some medical conditions (i.e., pain management, migraines, IBS, etc.) but will require a signed release from your doctor or appropriate health care professional to avoid masking symptoms before proper diagnosis and/or medical treatment has been obtained. Of course, non-medical issues (i.e., smoking, weight loss, confidence, etc.) will not need a form. I understand Hypnotherapy is not a replacement for medical treatment, psychological or psychiatric services or counselling and I also understand that the Hypnotherapist does not treat, prescribe for or diagnose any condition.

RELEASE STATEMENT: I give my full consent to receiving sessions by Tania Davies and Mindful Impact™ for the purposes outlined in this intake form and for future purposes that I may request. I understand that the success of my sessions depends greatly on my own ability and desire to affect change in myself. I understand that the results of my session(s) depend greatly upon my own serious participation and that Tania Davies and Mindful Impact™ cannot offer any guarantee of the success of my treatment. I am aware, however, that Tania Davies and Mindful Impact™ will do everything in their power to ensure my success and I agreed to participate in each session to the best of my ability. I hereby release Tania Davies and Mindful Impact™ from any liability. I also understand that I have other choices from which to seek assistance regarding my specific concerns, and I have chosen NLP/Coaching/Hypnosis/Psychotherapy at this time. I have been advised that I am free to terminate any or all sessions at any time. I have accurately provided background information as requested by Mindful Impact™. I understand that, during the session/s, the practitioner may touch me as part of the necessary techniques. The practitioner will always advise of the location of described touch and I hereby give my permission for such touch to take place when necessary.

I HAVE READ MY CLIENT RIGHTS AND I FULLY UNDERSTAND WHAT I HAVE READ.