Client Form Life in Harmony WA Client Form Full Name Date of Birth Address Email Contact number The Reason why you are coming for Hypnotherapy/Reiki Are you currently receiving psychiatric/counselling and/or therapy with another practitioner? Yes No If Yes, under whose care, and where Please list all prescription medication(s) you currently take, and the condition(s) for which you take them Are you currently using any recreational drugs? Yes No If Yes, please detail Have you ever been diagnosed with any of the following conditions? Depression Anxiety Bi-Polar Disorder Epilepsy Obsessive Compulsive Disorder Post Traumatic Disorder Other Medical Conditions Heart Cholesterol Diabetes High Blood Pressure Pain Allergies Asthma Bronchitis Emphysema Breathing Problems Insomnia Headaches Stomach problems Bowel problems Urination problems Sexual problems Cancer Brain injury Headaches Other Medical Conditions not listed Please select anything that you are uncomfortable with, or upset by: Spiders Heights Enclosed Spaces Germs Flying Snakes/Reptiles Water Darkness Blood Knives Rats/Mice Crowds Anything else that is not listed above What, (if any) therapy, lifestyle or attitude changes have been partially successful in making you feel better? Have you, at any time, seriously considered or attempted suicide? Yes No If Yes, please provide full details of the circumstance(s) Please provide the name, address and telephone number of your GP and/or Hospital Consultant Is there anything else that could be connected with the issue that Life In Harmony WA should know about before we start the therapy? Yes No If Yes, please detail Do you give permission for Life in Harmony WA (Tracy King) to contact your GP and/or Hospital Consultant if we deem it strictly necessary? Yes No PLEASE CAREFULLY READ AND NOTE THE FOLLOWING CONDITIONS (tick the box if you agree) 1. I have been advised by Life in Harmony WA (Tracy King) the scope of the therapies provided and give my full consent to receiving therapy sessions from Life in Harmony WA. I understand that results vary from person to person, and the agreement by Life in Harmony WA to work on the issues or problems presented by me, using whatever model or models are appropriate to my situation, in no way implies or guarantees a ‘cure’ of the said issues or problems. 2. I understand that Hypnotherapy, or any other therapy, website content, promotions or information sheets provided by Life in Harmony WA, is not a replacement for medical treatment, psychological or psychiatric services or the appropriate counseling. I also understand that Life in Harmony WA does not treat, prescribe for, or diagnose any condition. I declare that, if advised prior to any session with Life in Harmony WA to seek medical approval, I have consulted with my General Practitioner and/or health care practitioner and gained the appropriate medical approval for working with Life in Harmony WA. 3. I have been advised that I am free to terminate any or all sessions at any time. I have agreed to participate in each session to the best of my ability, and that contact between sessions will be strictly limited to telephone, email or letter. 4. I have accurately and truthfully answered the questions in Life in Harmony WA’s Consent Form and provided background information as requested by Life in Harmony WA. 5. I agree that reports requested by insurance companies, doctors, employers, courts, etc. will not be released without my written permission, and will incur a nominal fee of $20.00 to prepare and provide. 6. I understand that any mp3 download or CD is provided for me at Life in Harmony WA’s discretion. I agree that any such mp3 download or CD is for my personal use only and that it is not to be lent, copied or sold under any circumstances. I understand to not listen to hypnosis recordings while driving a car or operating machinery. 7. I understand that home visits will be made by Life in Harmony WA only in exceptional circumstances, and should I require a home visit I agree to pay an additional fee to cover Life in Harmony WA’s travel expenses. 8. I give permission for Life in Harmony WA to register our hypnotherapy sessions for the purposes of preparation for further sessions. I understand that I can request a copy of the session at any time. 9. Confidentiality is paramount and will be maintained in all but the most exceptional circumstances. I agree that these can include: legal action (criminal or civil court cases where a court order is made demanding disclosure, including coroners’ courts); child abuse; if I am an imminent danger to myself or others; and where there is good cause to believe that not to disclose would cause danger of serious harm to others. Most standards of confidentiality applied in professional contexts are based on the Common Law concept of confidentiality where the duty to keep confidence is measured against the concept of ‘greater good’. The sharing of anonymous case histories with supervisors and peer-support groups is not a breach of professional confidentiality. 10. Life in Harmony WA has reserved your session for you and it is their policy to charge the full amount of the session for cancellations received with less than 24 hours’ notice, or non-attendance. Non-attendance of a fee-paying booked session without prior warning will result in a charge being made that is equal to the fee of the session. Such fees are charged at Life in Harmony’s discretion, and I agree to pay fees incurred in those circumstances.I agree to the terms stated above. Submit
