Den Clare: online consultation registration form

Den Clare - The Hypnotherapy Consultancy

CLIENT INTAKE & CONSENT FORM

CONFIDENTIAL

This intake form is to be completed and signed by all my new clients. The information you provide will become part of your confidential paper records, and will be destroyed within one year of your using my services. I keep no electronic records and do not share information. Once you have submitted this form I will contact you to schedule an appointment.

Your name

Your email

Your Skype or Zoom or Messenger address

Your date of birth

Your address and postcode

Contact phone number

Your occupation, if any

What can I help you with?

This part of the form allows you to tell me a little about the reasons you are asking for my help. Please include as much or as little information as you feel comfortable to share.

Describe the main problems

Can you think of a recent example when you felt like this? Describe what happened.

Is this situation typical of what happens? Where is it most likely to happen? When does it happen? Who are you most likely to be with? How does it happen?

How often does this happen? How distressing? How long does it go on for when it happens? How does it usually start?

What helps? What makes things better? E.g. avoidance, substances, safety behaviours

Impact - How does this problem affect your daily life? Work, home, family/friends, study

Coping resources - What helps you cope generally? Enjoyment, achievement, relationships, spirituality

What brings you to therapy at this time?

How did you hear of me?

What do you hope to achieve in therapy? What will be different?

What medication do you take?

Do you use alcohol, drugs, tobacco, other substances? How much?

General mental state - Mood, concentration, memory, sleep, weight changes etc.

Risk – self-harm: thoughts, plans, likelihood to act etc. Other risks?

Previous therapy / treatment - What have you tried before? What helped? What didn’t help? Any other comments?

Is there anything else you'd like to tell me about?

Do you give consent for me, the therapist, to collect and process the information on this form for the pursuance of both my own and your own legitimate interests? (You must agree this to proceed)

You must put something in every box. So if the form does not send, check you have not left any empty.

Tel: (01983) 866999
denclare3@gmail.com
My Skype address: denclare3
Den Clare, 16 St Boniface Cliff Road, Shanklin, Isle of Wight. England PO37 6ET.

Terms and conditions

Any information given by you will be treated in confidence and in accordance with the General Data Protection Regulation (GDPR) and UK law.
By returning this form you agree with the terms and conditions and are confirming that all the details you have given are true and correct.
Please be aware that the information you provide may be highly personal and so you should ensure that it is sent to me by a secure method for example you may wish to password protect the file and send me the password separately.
This information will not be used for marketing purposes.
The maximum time this information will be held is 3 years. You have the right to ask for this information to be deleted at any time and can do so by requesting deletion of information to denclare3@gmail.com.
I reserve the right to decline or discontinue working with any client without having to declare any reason. For example, but not limited to, if you arrive for your appointment intoxicated or under the influence of recreational drugs, I reserve the right to stop the appointment or decline seeing you.
Payment must be made prior to commencement of the sessions. Payment can be made online, by cheque (in advance) and by cash.
I operate a strict policy of 48 hours’ notice required to cancel or move an appointment. If this is not given, I reserve the right to charge the full session amount.
Any missed appointments without 24 hours notice, will be charged for up to the full amount.
Due to the obvious fact that I am dealing with human behaviour I am unable to give a blanket guarantee that we will be successful. What I endeavour to do is ensure that there is a clear understanding as to how much work needs to be done to help you achieve the changes that you want. My promise is to terminate our work together should I feel I can no longer help you change.
The Hypnotherapy Consultancy is not a medical practice. Please make sure you have seen your medical and or dental practitioner to exclude treatable causes prior to making an appointment. The Hypnotherapy Consultancy cannot diagnose, any comments made by me should not be taken as medical advice and will be made only in response to your comments, beliefs and understandings.

This form is hosted by Pinkeye Graphics Ltd and provides a confidential service to submit information directly to Den Clare. Your information is not viewed or retained by Pinkeye Graphics Ltd.

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