Client Intake Form | Hypnotherapy with Olivia Mak

All About You Wellness Centre

Client Information Sheet

Name : *

First

Last

Date of Birth *

Occupation *

Current Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

HK ID Card/ Passport Number *

Contact Number: *

Other Contact Number:

Email: *

Gender *

Male
Female
Non – Binary
Prefer not to say

Status *

If divorced, how long:

Have you ever done any counselling, hypnotherapy or meditation? *

Yes
No

If yes, when?

What was the reason? *

Did it work for you? *

Please complete the following sentences in your own words:

My relationships are: *

Money is: *

Life is: *

I am: *

What are the 3 major events that have shaped your life? Briefly describe how the event impacted you and state your age. *

Example: Age: 10, Event: My Grandfather died. So I felt lonely and abandoned. I experienced the sense of loss for the first time.

Please describe in your own words what you would like to accomplish in your sessions. How you would expect your life to change once you accomplish it? *

Please rate the following areas of your life on a scale of 1 to 10, with 1 being very poor and 10 being excellent.

Physical Health *

Emotional Health *

Relationship (primary) *

Friendships *

Spiritual Health *

Job or Career *

Financial Prosperity *

Sense of Purpose *

Assertive Ability *

Time Management *

For each of the statements below, if the answer is “yes” put a check mark.

EMOTIONAL HEALTH *

RELATIONSHIPS *

I have a positive primary relationship (spouse, life partner, or close friend)
I tell my family and friends frequently that I love and appreciate them
I have friends I can call and ask for support when I need it
I spend quality time with my friends and family
I rarely experience cravings for sugar
I have dealt with old hurts and forgiven my friends and family
I am comfortable spending time alone with myself

SPIRITUAL HEALTH AND SENSE OF PURPOSE *

I feel connected with a Source greater than myself
I have a regular spiritual practice such as meditation or prayer
I have friends with whom I can discuss my spiritual beliefs
I know my purpose in life

CAREER *

I feel fulfilled in the job or career I have now
I have some unique skills and abilities
I know what I ultimately want to do
I have opportunities to express my creativity in my career
My current job pays me what I am worth

FINANCIAL PROSPERITY *

I feel prosperous
I live within my means
My credit cards are paid off
I spend and save money wisely
I pay my bills on time
My tax filings are up-to-date
I know that having more money is not the answer to my problems.

ASSERTIVENESS *

I feel comfortable saying no to friends and family
I easily express my needs and can ask for support
I am comfortable in new social situations
I can discuss criticism of my behavior without getting defensive
I am able to confront someone I feel is taking advantage of me
I easily compliment myself and others

Are you in therapy or taking medication? *

If yes, please explain.

What else would you like your practitioner to know about you?

What is your level of commitment to resolve your issues from the scale of 1- 10, Please Tick the scale below, 1= least and 10= most?

How did you hear about All About You Centre:

Terms and Conditions

Cancellations must be made at least 24 hours prior to the scheduled appointment. If cancellations are made less than 24 hours the full session fee will be charged. Should the client fail to show up, the full session fee will be charged.
All prior payments are non-refundable and non-transferable, except in special circumstances and All About You (‘AAY’) reserves the right to the final decision.
The Client agrees that all practices done on, for, or even by them at AAY are done with their full consent and at their will.
The Client attests that they have no mental or psychological ailment/disorder and are not on any psychiatric or psychological treatments and/or drugs.
The Client agrees to indemnify, release, remise and forever discharge, the treating practitioner, AAY, its employees, its consultants, its property owners or anyone one at AAY from any obligation or liability whatsoever, all claims, demands, damages, injuries, actions or causes of actions whatsoever, before, during or after volunteering to participate in such sessions.
The Client is aware of the modalities of therapy used and understands that the result may also depend on external factors and the clients’ own efforts.

Privacy
By signing this form, you understand and agree: Your personal data (name, contact details, interests,) may be used by AAY to contact you and inform you about our latest news, events, promotions, offers, workshops, seminars and other exciting happenings at AAY. Please note that you may change your mind at any time and ‘opt-out’ of our mailing list by either writing to us at info@soniasamtani.com or by clicking ‘Unsubscribe’ in any of our email communications.

Confidentiality
All information discussed in the sessions will be treated as confidential information and will not be disclosed to any third party unless prior permission is granted or unless disclosure is required by law. However, counselors are ethically and/or legally required to disclose confidential information to the appropriate authorities in four kinds of circumstances:

● If a client indicates that they or another person may be a danger to themselves or others
● In the case of apparent, suspected or potential child abuse or neglect
● If clients report sexual abuse by a regulated health professional
● When a court issues a summons for records of testimony

From time to time your practitioner may consult another for supervision, in order to improve the quality of services provided, without using personally identifiable information. Other than the four circumstances listed above, your practitioner cannot converse, write or give any information about you or your circumstance, without your verbal or written informed consent to do so.

General – Informed Consent
The purpose of your sessions here is to help you improve your current circumstance(s) and our aim is to contribute to your well-being and growth. Sessions involve delving deep into the root of the problem/s and it is not uncommon for clients to feel an increase in symptoms before they feel better. However, the potential benefits of counseling are numerous. Should you have any questions, concerns or suggestions regarding the information provided above or any other aspect of the counseling process, feel free to discuss with your practitioner. Should you choose to discontinue sessions at any time it is highly advisable to discuss the reasons for considering this with your practitioner prior to acting on your decision.

I have read and accepted the above terms and conditions above.

(This agreement is valid from the date signed until further notice.)

Please type your name to confirm all the information above. This will serve as your e-Signature. *

Date Signed: *

Client Information Sheet for Hypnotherapy Sessions with Olivia Mak

All About You Wellness Centre

Client Information Sheet