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Sign In
My Account
About
1:1 Private Sessions
Training
Events
Bookings
Subtle Self
Name
*
First Name
Last Name
Preferred name
What are your pronouns?
For example, she/her, he/him, they/them
Date of birth
MM
DD
YYYY
Address
*
Phone
Country
(###)
###
####
Email
*
Occupation
Relationship status
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
Country
(###)
###
####
General Practitioners Name & Practice Name
Do I have permission to contact your GP if needed?
This may only be relevant in the instance of particular illnesses / medication contraindications etc.
Yes
No
Only if you discuss with me first what you will be communicating with them
Brief Medical History (inc mental health, physical health etc.)
Do you smoke
Yes
No
Have you ever experienced psychosis
Yes
No
Do you currently experience suicidal thoughts
Yes
No
Please list any medications you are currently taking (including all western medicine prescriptions, alternative medicines and psychedelic substance use)
Any known allergies
Have you ever used used Flower Essences
Yes
No
Brief family history
What is your living environment like
(living alone, with others, harmoniously, in a stressful household etc)
Have you ever experienced hypnotherapy
Yes
No
What is your belief system / religion (if any)
Are you a member of Victoria Police
Yes
No
Are you a student of Hypnotherapy Training Australia
Yes
No
Are you an NDIS participant
Yes
No
Do you experience or have an interest in addressing any of the below
Anxiousness
Stress
Fears
Grief
Phobias
Panic Attacks
Guilt
Depression
Confidence
Self esteem
Body image
Motivation
Achieving goals
Sexual issues
Fertility
IVF
Conception
Pregnancy
Birth
Pleasure
Addictions
Alcohol
Smoking
Drug use
Gambling
Compulsive behaviour
Disordered eating
Poor food /diet
Movement / exercise
Pain
Any diagnosed illnesses / syndromes / diseases
Relationships
Sleep
Childhood problems
Other
What would you like to work on in our time together
Please describe the symptoms and any triggers or habits you have as a result of this area of your life, if any
How often do you experience these
What does this stop you doing
How does this make you feel and why
Has anything in particular helped so far
If you could achieve anything from our time together, what would you like that to be? How would you like to feel?
Declaration: The information which I am providing is the closest and most accurate description of my situation that I am able to disclose at this moment. I confirm that I have been advised by Jacqueline Thomson of the scope of the therapies that she provides and give my full consent to receiving therapy sessions from Jacqueline Thomson. I understand that results may vary from person to person and the agreement by Jacqueline Thomson to work on the issues or problems presented by me, using whatever therapeutic model or models are appropriate to my situation, in no way implies or guarantees the resolution of any presenting issues or problems. I understand that hypnotherapy and any other therapy or information provided by Jacqueline Thomson, either in person or via telephone, email or internet is not a replacement or substitute for medical, psychological or psychiatric treatment. If I have any doubts or concerns about my health, I will seek advice from an appropriate qualified healthcare professional. I declare that, if advised by Jacqueline Thomson prior to any therapy sessions, to seek medical approval, I will consult with my GP, hospital consultant and/or other healthcare professional and gain the appropriate written approval for Jacqueline Thomson prior to the next therapy session. I have been advised that I am free to terminate any or all sessions at any time. I have answered accurately and truthfully and provided background information during the initial consultation and will continue to do so during any subsequent therapy sessions
I agree
Thank you! Jacqui has now received your intake form. Can’t wait to see you in Session One
