Intake Questionnaire Please do your best to answer all questions. Name* First Name Family Name Current Age*Address Phone numberEmail* Emergency ContactName Phone NumberPersonal HistoryWhat is the Presenting Problem?How long have you been aware of it / experiencing it?How will you know when it’s gone?How would you like to feel?What is your current relationship status? Do you have children? If so how many, and what ages? Have you had any accidents, illnesses, injuries, traumas or shocks? (including childhood)Please dot point.Are there any current health issues? (e.g. heart condition, epilepsy etc.)Have you experienced or been diagnosed any of the following:? Depression Anxiety Bi-polar disorder Eating disorders Sleep disorders Trauma Grief Obsessive Compulsive Disorder ADD / ADHD Self harm Suicidal thoughts PTSD Alcohol dependency Smoking addiction Borderline personality disorder Schizophrenia Psychosis Phobias of any kind Phobia of lifts Phobia of water List of 10-12 most distressing events or periods of extreme stressAge - Event / Period of extreme stress - Names of who was there e.g. Birth - Forceps Delivery - Mum, Doctor 2 years old - Dad left Mum - Mum, sister, brother 12 years old - Horse Riding Accident - My ParentsAre you currently seeing a therapist? If so what kind of therapy?I would like to work in concert with your therapist.Do you have any allergies?Do you live alone or with others? Who pays the bills and who does the cooking and cleaning? Who do you rely on in your daily life? Who do you talk to when you are upset? Who provides your emotional and practical support? Family HistoryWho lived in the household when you were a child? Do you have any siblings? How old are they? How often did you move? Who was your primary caretaker? Who in your family was affectionate to you? Who treated you as a special person? Was there anyone who you felt safe with growing up? Who made the rules at home and enforced the discipline? How were kids kept in line-by talking, scolding, spanking, hitting, locking you up, manipulating? How did your parents solve their disagreements? How would you describe the atmosphere in your childhood home?Your privacyThis therapy service is confidential, and your personal information will not be disclosed to any 3rd parties without explicit written consent, unless I have serious safety concerns.Consent*I understand that hypnotherapy and the psychosensory therapies are uniquely effective processes, useful for improving mental and emotional health. I also understand that for a successful outcome to occur, the client is required to positively support the process with deliberate conscious decision making. A positive outcome relies not only on the quality of the practitioner, but also on positive proactive support and engagement on the part of the client. I understand that having private consultations – in person, by telephone, or online – with Karen Corbett, using Havening, EFT (Emotional Freedom Techniques) and/or The Richards Trauma Process (TRTP), is not - and is not intended to be - a substitute for medical and/or psychological diagnosis and treatment. I also understand that practitioners of these techniques do not diagnose conditions or interfere with the treatment of a licensed medical professional. I agree that even if I notice dramatic improvements as a result of consultations with Karen Corbett, I will not cease any medically prescribed treatment without first consulting my licensed medical or health care professional. I hereby waive any and all claim of liability against Karen Corbett. Δ
