Client Intake Form

Fields marked with * are required
Please select the types of therapy you are seeking
please enter your contact number
Please enter a contact number in case of emergency
Details of person organisation that have referred you
please enter brief description of your expectations from therapy
These are major areas of concern that you would like to address. Please tick all that apply.
These are other areas of concern that you would like to address. Please tick all that apply.
Please enter any other areas of concern you would like to address here
please enter any other notes or details that you would like to add

I hereby authorise: _____ Mark Spooner ______, to hypnotise me for the purposes outlined in the Intake Form and for any future purposes that I may request.

I understand that the success of my therapy depends greatly on my own ability and desire to affect change in myself.

I am aware that _______ Mark Spooner ______ will do everything in his power to ensure my success.

I also understand that I have other choices from which to seek assistance regarding my specific concerns and I have chosen psychotherapy/hypnotherapy at this time.

I, NAMED ABOVE, understand that any sessions provided by Mark Spooner (Holistic Therapist) is intended as an alternative treatment and not in place of medical treatment.

I am aware that Mark Spooner will not diagnose illness or disease, will not prescribe medications, and that it is my responsibility to seek medical advice from a physician about an illness I may have. I also understand that I might experience some minor reactions while my body adjusts to the holistic treatment.

I have informed Mark Spooner of all my known physical conditions, medical conditions and medications, and I will keep you updated on any changes.

I confirm I am over 18 years of age.