Client - First Name
Client - Last Name
Client - Date of Birth
Client - Gender
Guardian Details (if client is under 18 Years)
Guardian Full Name
Mobile Number (include Country code if outside Australia)
How did you hear about Mindful Impact?
Client or Physician Referral - their name
Is the client currently suffering from any of the following (tick all that apply):
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?
Doctor's full name
Name of medical practice
Address of Practice
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.):
Please briefly share anything else that would be helpful to know about you, (i.e., recent life-changing events such as deaths, divorce, relationships, job changes, health issues, past trauma, accidents, etc.)
List your three favourite places to be (e.g. beach, forest, snow, city etc.):
Have you experienced hypnotherapy or hypnosis before?
What is currently your most important life goal?