Ocean Tides Therapy - Intake Form

Please complete this form as fully as you can. The information helps your practitioner provide safe and effective care. If any question is unclear or you would prefer to discuss it in person, leave it blank (or enter N/A) and raise it in your first session.

Section 1 - Your details

Name

Phone

Email

Address and postcode

Gender

Pronouns

Occupation

Name and phone number of emergency contact

Relationship with emergency contact

May we contact this person in an emergency?

GP and referring practitioner (if applicable)

Clinic / practice phone

Referred by (if applicable)

Section 2 - Current health and treatment

Are you currently taking any medication (prescribed or otherwise)?

If yes, what is the name of the medication?

Are you currently seeing another therapist, psychologist or psychiatrist? If yes, name and contact details (so we can coordinate care if appropriate).

Have you had hypnotherapy before?

Do you currently smoke or vape?

Section 3 - Lifestyle

Please describe your alcohol consumption

Please describe your quality of sleep

Section 4 - Mental health history

Have you ever been diagnosed with, treated for, or experienced any of the following? (Tick all that apply)

If other, please describe here

Have you ever been admitted to hospital for a mental health reason? If yes, approximate year(s) and brief detail:

Section 5 - Physical health

Do you currently experience any of the following?

If other, please provide details

Section 6 - Safety and wellbeing

These questions are routine. They help your practitioner provide the right level of support and, if appropriate, connect you with additional services.

In the past two weeks, have you had thoughts that you would be better off dead or of harming yourself in some way?

Have you ever attempted to take your own life or seriously self-harmed?

Are you currently having thoughts of harming another person?

Do you currently feel unsafe at home or in your relationships?

Section 7 - What brings you here?

What would you like help with?

In your own words, what would you most like help with right now?

If our work together is successful, what would be different in your life? What would you notice yourself doing, feeling or thinking?

On a scale of 0 to 10, how much is this concern currently affecting your day-to-day life? (0 = not at all, 10 = completely overwhelming)

How did you hear about Ocean Tides Therapy?

Section 8 - Privacy and how we use and protect your information

Your information is collected on this form so that your practitioner can provide safe, appropriate care. Your information may be reviewed during clinical supervision for educational and quality-assurance purposes. In this case your information will be de-identified. Records are stored securely and handled in accordance with the Australian Privacy Principles. You may request access to, or correction of, your information at any time by contacting Ocean tides Therapy.

SECTION 9 — Limits to confidentiality

What you discuss with your practitioner is confidential. There are limited situations in which information may be disclosed without your consent:

• where there is a serious and imminent risk of harm to you or to another person;

• where a child or vulnerable person is at risk of abuse or neglect (mandatory reporting);

• where records are subpoenaed or otherwise required by law;

• for clinical supervision and case discussion with supervisors, in which your identifying details are not disclosed unnecessarily.

Section 10 - Consents

I understand and accept the limits to confidentiality described above.

I consent to the use of clinical hypnosis as a therapeutic tool during my sessions.

I understand that I am seeking complementary, non-medical treatment, which may not replace conventional medical or psychological care.

Section 11 - Optional consents

I would like to be kept informed of workshops and resources that may support my therapeutic work.

I am willing to be contacted about a short anonymous questionnaire for research or training purposes in the future.

Section 12 - Billing

Health fund rebates for hypnotherapy vary between funds and levels of cover and may change without notice. We are unable to confirm whether your policy will provide a rebate — please check directly with your fund.

Cancellation policy: I understand that unless I give at least 24 hours notice of a session cancellation, I may be charged for that session.

Please ensure you have sufficient funds in your account on the day of your session.

Please use this space to provide any other information that you would like your practitioner to know before your first session.

I understand that checking yes constitutes a legal signature confirming that I acknowledge and agree to all of the above terms.

Please type your first and last name.. and today's date.