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Intake Form

Please note: Whilst this form is lengthy to complete, the details provided will ensure smoother and faster progression toward your appointment and less time wasted during your appointment.

    Your Full Name*:

    Date of Birth*:

    Phone Number*:

    Email Address*:

    Your Address*:

    Are you currently under the care of another health care provider?*:

    If applicable, please advise your GP's, Therapist or Specialist Name and Phone Number:

    Have you ever been diagnosed by any doctor with a mental illness?*:


    If YES, please advise what was diagnosed:

    Are you currently taking any medications?*:

    If YES, please provide information about what medications you are taking and why they were prescribed:

    How did you hear about Ahh Haa Hypnotherapy?*:

    If your answer above is OTHER, please provide details:

    Have you had hypnotherapy before?*:

    Are you a smoker?*:

    Describe your alcohol consumption*:

    If your answer above is OTHER, please provide details:

    Describe your quality of sleep*:

    If your answer above is OTHER, please provide details:

    Do you currently suffer from any of the following? (Select one or more please)*:

    Have you ever suffered from any of the following? (Select one or more please)*:

    Do you suffer from any of the following? (Select one or more please)*:

    What is it you expect we can help you with?*:

    If your answer above is OTHER, please provide details:

    Health Fund Member - If you are a member of a health fund - please provide its name :

    Health Funds (Acknowledgment of your Understanding):

    Health fund rebates vary between funds and levels of cover. Additionally, changes in policy can occur at any time. We cannot tell you if your particular insurance policy will cover your Hypnotherapy, Psychotherapy, Coaching or Counselling sessions, or what rebate you may be entitled to.

    Session Cancellations:

    I acknowledge that, unless I give a minimum of 24 hours’ notice of a session cancellation, that I may be charged in full.

    Privacy & Disclosure (Answer required):

    I understand that the sessions are bound by all Privacy related laws and governances. Please note: Your session is subject to the rules of confidentiality. Nothing you disclose will leave the session or be relayed to others. However, there are exceptions to these rules of confidentiality. Any situation, where you are at risk of harming yourself or others or your involvement in a serious crime, your therapist, as a Mandatory Reporter is legally obliged to report these incidents to the relevant authorities.

    Therefore: I understand that if I disclose that I have, or intend to commit certain criminal offences, the therapist is obliged by law to report me to the authorities. I further understand that when there is a requirement to refer clients that there are aspects of my treatment plan that may be provided to other health providers for ongoing care treatments.

    If you are concerned, please refer to our information regarding “Legalities” including Confidentiality, Informed Consent, Mandatory Reporting and Limits to Confidentiality, prior to your first appointment). You may also ask your therapist to clarify any points prior to proceeding.

    Use of hypnosis as part of therapy: (Must be answered):

    I understand & acknowledge the following:

    1. That the Therapist will use hypnosis as a part of the treatment plan and that I am seeking alternative / non-medical treatment that may not be supported by or endorsed by established medical practice.

    2. That as part of my therapy I may be asked to complete homework, which is designed to help me to be fully engaged with my therapeutic process. I am willing to engage in homework & tasking as requested.

    3. I am responsible for and expected to complete any tasks or homework.

    4. That the more I engage in my therapy process, the more I will progress towards my therapeutic goals.

    Consent to use Hypnosis (Answer required)

    Informed Consent: It is important that you clearly understand and agree to the therapy. If you have any questions about the therapy being provided, please ask your therapist so that you are fully informed and give your consent to therapy. NB: Proceeding with the therapy in your sessions is deemed as your consent as you could cease the session at any time. Hypnosis is a focused state of attention, essentially you will be able to choose to work with your therapist and can stop the Hypnosis at any point, even whilst in the hypnosis component of the treatment if you wish to do so.

    Note:

    1. In agreeing to the above, please be aware that if you have matters to discuss with your therapist, that may include any pending court action, please seek legal advice regarding that matter and its discussion, prior to raising that specific issue or issues with your therapist.

    2. Your therapist will treat details as confidential, but your legal counsel may instruct you to be clear about what areas you will need to exclude from Hypnotherapy in some unusual circumstances. It is your choice to discuss any specific topics with your therapist and should be aligned with your understanding that your informed consent has been given by you and is accepted.

    3. It is important to also be aware that if you do have any pending action/court related issues, that you can still seek assistance from your therapist, who may instead utilise other modes of therapy for that identified aspect, including but not limited to Strategic Psychotherapy, but with the clarity that for those issues identified by you, per the above, Hypnotherapy/Hypnosis is to be excluded as a component of your care by your therapist until you advise the matter is no longer related to any current or pending court matters. (In relation to the "Per se exclusion rule 'regarding hypnotizing a witness and their testimony'' which is in use in some courts in the USA)

    Informed Consent to Teletherapy/Telehealth Services:

    Video Sessions known as Telehealth or Teletherapy may be used as & when required due to physical distance requirements (Ahh Haa Hypnotherapy is based in Queensland, Australia).


    Provision of a Telepathy Service: Teletherapy services includes therapy sessions provided by video or phone call, with preference for video call as this is closest to in-person therapy sessions. Once a Teletherapy session is scheduled your therapist will email you a secure link to be able to connect to your Teletherapy session with your Therapist via the Teletherapy platform used.


    No software needs to be downloaded. Teletherapy services require clients to have a secure and reliable internet connection and a device (i.e., smartphone, iPad, laptop, desktop etc) with a camera, microphone and speakers.


    It is advisable for clients to choose an environment for each session where they are not likely to be distracted, interrupted or overheard, and one that has minimal noise disturbance.


    Clients are encouraged to also choose an environment with good lighting and consideration of the background as it may be visible to your therapist. Because clients may be in varied locations for their Teletherapy sessions, Ahh Haa Hypnotherapy will require clients to provide their location at the commencement of each session.


    Please be aware that clients are responsible for any costs associated with setting up the technology needed so they can access Teletherapy services and their data or call usage. Ahh Haa Hypnotherapy will be only be responsible for their cost associated with the platform used to conduct Teletherapy services.


    Clients should be aware that problems may occur due to connection issues causing image delays or less than optimal image quality. Video calls generally limit the amount of nonverbal information exchanged between therapists and clients and as a result, there is greater potential for misinterpretation.


    Clients are asked to please have patience with the process and clarify information if they think the therapist has not understood them well and to also be patient if she asks for periodic clarification. Please note that the therapist will be taking notes and at times will need to look down during Teletherapy sessions to record these.


    In accordance with legislative requirements, electronic records and paper records are kept in secure storage. Ahh Haa Hypnotherapy therapist will not make video or audio recordings of Teletherapy sessions and clients are asked to respect Ahh Haa Hypnotherapy therapist’s privacy by agreeing not to make such recordings of Teletherapy sessions and not to use materials from the sessions for purposes other than therapy (e.g., posting any portion of said sessions on internet websites such as Facebook or YouTube or other shared spaces or social media is not permitted). Note that in sessions ONLY the '"Hypnosis / Hypnotherapy component" will be audio recorded and that you and the Therapist will agree at that time of that component beginning - as to who is making that recording and how this recording is being made, for use as part of the homework by you as a client. This audio recording is intended for therapeutic purposes only and is yours to use indefinitely. (Note it is important to ensure that you have a personal copy of that recording as your therapist may not have that recording ongoing to share with you in the future due to the limitations of storage of electronic data and recommend that you save your audio in a safe and accessible place for continued use & access indefinitely.)

    Procedures in case of technical difficulties or disruptions in service: If there is ever a disruption of services on the internet or technical difficulties Ahh Haa Hypnotherapy’s therapist will message or call you the client to discuss how to proceed with the session. If reconnection is not possible within 10 minutes Ahh Haa Hypnotherapy’s therapist will call &/or send an email to schedule a new session time.


    Privacy: The privacy of any form of communication via the internet is potentially vulnerable and limited by the security of the technology used. To support the security of your personal information Ahh Haa Hypnotherapy’s therapist uses up-to-date security software which is inclusive of end-to-end encryption to protect your privacy. AGREEMENT: By agreeing to participate in a Teletherapy sessions, I agree to expressly release Ahh Haa Hypnotherapy’s therapist from any liability associated with unintended cyber security issues and/or difficulties with unsecured communications.

    (Electronic Signature at the end of this form &/or your proceeding with any Telehealth session indicates your consent to ALL of the above)

    Preferred Telehealth Platform

    If you wish, please nominate which Devices & or Apps you have or can use in the space provided please. Telehealth: Note that our preferred Telehealth platform is simple to use, very secure and able to be used on any device with no downloads or special apps - so we will generally default to :
    ZOOM (and invitation will be sent).

    Other platforms are: WhatsApp, FaceTime, Facebook Video, etc.

    Nominate your preferred telehealth platforms:*

    Work History & Hobbies

    If you are currently working please advise what kind of work that you do, plus/&/or what work you have done in the past - It is also very helpful to know what hobbies and pastimes you really enjoy, and to also use this space to provide any other information that you feel may be relevant

    Detail Work History & Hobbies:

    Physical/Medical Conditions

    Must be understood and answered.

    If your presenting issue manifests with physical symptoms, we cannot treat you unless you can show us that you have been cleared of any underlying physical issues. Problems like constant headaches or migraines, back and neck pain, tinnitus, irritable bowel syndrome, psoriasis, alopecia, bedwetting, allergies, eczema, weight loss, restless leg, immune system deficiencies, cancer and alike must first be checked with a medical professional, and a medical reason for the issue has been discounted before we can treat you ethically.

    N.B. Sometimes people’s philosophies about the root cause of an issue can preclude investigating appropriate answers to the issues. For some people everything has an emotional root. We are not of this opinion, and such extreme views can be harmful.

    This caveat is demanded out of our duty of care. For example, we want to know that headaches are not a symptom of a larger more serious issue that will be ignored if we help you minimize the discomfort. We will want to see evidence of your medical history and may wish to speak to your doctor about your treatment options. Our preference is that we see you with your GP’s knowledge and cooperation.

    Medical Disclosure

    I have pursued all reasonable medical avenues to deal with the presenting issue, and have been informed by my medical practitioner that it is not physical but a psychosomatic issue, or alternatively, it is a physical issue but there is nothing more the medical system can do for me.

    Terms Acceptance: I understand that checking this box constitutes a legal signature confirming that I acknowledge & agree to signing the above terms. (Where possible I also agree to signing and dating the hard copy document which will be compiled from this online form) - I also note that I have read and understood “Legalities” (link) at the completion and submission of this form regarding engagement as a Ahh Haa Hypnotherapy client. I confirm that proceeding with any session is also providing your implicit consent to engaging with this therapy each time.

    Please type your full first and last name*:

    Electronic Date/Submission*:

    Health Care PLAN Details

    Only applicable if on a PLAN: Only needed if you are engaging with your therapist specifically under any of the following Health Management Plans - please provide those details in the following areas: 1) Please name the specific : Health Care Plan, Insurance Plan &/or Provider or Employer Scheme for this service, please advise who here - i.e. NDIS, NDIA, The Company & or Your Company /Work Health Plan, Insurance, Workers Compensation Plan, etc. (If any)

     

    Health Care PLAN Details:

    PLAN Code/ID or reference number:

    Health Care PLAN - Start & End Date :

    Company Name - That is Providing or Managing the Health Plan: If the above applies, What Company provides this plan - i.e. Which entity/company is the: (Type the right name - if any -) of any of the following: i.e. NDIS provider, Your Workplace, Your Insurance Company, or other.

    Contact Name of your PLAN Manager: If you have a Liaise person, Manager, Plan Manager, HR Manager or Company Services/health & Wellbeing Manager or Co-ordinator for the above Company - please give the persons NAME here so that I can work with them.

    Contact Phone Number of your PLAN Manager: If you have a Liaise person, Manager, Plan Manager, HR Manager or Company Services/health & Wellbeing Manager or Co-ordinator for the above Company - please give the Contact Phone Number here so that I can work with them.

    Contact Email Address of your PLAN Manager: If you have a Liaise person, Manager, Plan Manager, HR Manager or Company Services/health & Wellbeing Manager or Co-ordinator for the above Company - please give the contact email address here so that I can work with them (if any).

    Other PLAN Management details you wish to provide: If you have a Liaise person, Manager, Plan Manager, HR Manager or Company Services/health & Wellbeing Manager or Co-ordinator for the above Company - please provide any other relevant contact details you want here (i.e. Address and other details can be provided here).

     

    Updates and Questionnaires

    Would you like to be kept informed of workshops that would support and reinforce the work you have done here in the clinic?*:

    Would you be willing to answer a short questionnaire sometime in the future for research purposes?*:

     

    Contact Information

    Website: https://ahhhaahypno.com.au

    Provider: Megan Lawlor

    ABN: 919 323 642 39

    Phone: 0402 940 737

    Ahh Haa Hypnotherapy