As part of our work with you, it’s necessary to collect and record your personal information specific to our work together. Your personal and contact information is stored separately from your session records, while both sets of information are maintained and stored securely.

Before you complete this form please refer to our Terms of Service and Privacy Policy. As part of your client intake submission, you will be asked to agree to these policies.

Your Full Name *

First Name

Last Name

What is your preferred name for us to refer to you by?

e.g. Nickname or name you are more commonly known by

Your Email Address *

Your Phone Number *

Your Date of Birth *

YYYY

Your Residential Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Please nominate an Emergency Contact *

Please nominate someone we can contact if we have concerns for your wellbeing. You don't have to nominate a family member, it can be a close friend or someone you trust.

First Name

Last Name

What is your Emergency Contact's relationship to you? *

e.g. Spouse, Friend, Next of Kin

What is your Emergency Contact's phone number? *

Have you previously received any type of mental health support, such as counselling, psychotherapy, psychological or psychiatric services? *

Yes

If you answered Yes, what support have you received and has it helped you?

Are you currently working with any another mental health professionals? *

If you are, that's great! We encourage you to advise your mental health team that you are engaging with THINK Coaching & Hypnotherapy as part of your holistic approach to emotional and mental health and wellbeing.

Yes

Are you presently taking any prescribed medication such as antidepressants or antipsychotics? *

Yes

Have you ever experienced a traumatic brain injury or undergone brain surgery? *

Yes

How would you rate your current level of emotional wellness? *

Poor

Good

How would you rate your current level of physical health and wellbeing? *

Poor

Good

What is the main reason you decided to work with us? Be specific and share some background with us. *

What is another reason you decided to work with us? *

Why is it important for you to work with us to achieve your intended outcomes or goals? *

What thoughts, beliefs or blocks have been getting in the way of you achieving your intended outcomes or goals up until now? *

What approach would you like us to take so we can best support you? *

You can choose more than one option here.

Counselling: I just want someone to listen.

Counselling: Help me process my thoughts, ask me quality questions, and offer some helpful insights.

Coaching: I want to set achievable goals and learn new ways to achieve them. I'm open to doing some emotional resetting work to help me clear the blocks and move ahead in life.

Coaching: I'm aware of what's holding me back and I'm ready to do the mental and emotional resetting work to get past my blocks and move forward in my life.

Coaching: I know what I want in life and I'm willing to do what it takes to create a mindset that will support me to achieve my goals.

Therapy: I want to resolve the root causes of my mental and/or emotional issues (e.g. anxiety, depression, trauma, feeling stuck in the past) and start or continue the process of healing.

I want it all and I'm willing to try new techniques and approaches to generate new outcomes in my life.

Our Agreement: By submitting your Client Intake Form you give your consent to receiving holistic counselling, coaching and/or hypnotherapy and understand that Counselling, Mindset Coaching, Results Coaching, Emotional Freedom Techniques (EFT), Neuro-Linguistic Programming (NLP), Time Line Therapy™ Techniques and Hypnotherapy are classed as ‘complementary’ therapies. This means our coaches are qualified Complementary Healthcare Providers and not licensed General Practitioners or Medical Doctors, Psychologists, Psychiatrists or Social Workers. THINK Coaching & Hypnotherapy and its representatives including our coaches will always use their best endeavours to assist you to generate your intended outcomes and to achieve your goals. However, you, our valued client, always remain responsible for your personal care and safety, thoughts, choices, behaviours, and the outcomes and results of your coaching investment. *

I have read and understand the Terms of Service and Privacy Policy and understand I am responsible for the value I gain from working with my coach.

Thank you!

Your information has been emailed to THINK Coaching & Hypnotherapy.

We’ll contact you if we need any further information from you.

We’re looking forward to working with you :)

From little thinks big thinks grow

First Name

Last Name

Email Address

We value and respect your privacy as we do our own. It’s for this reason that your private and contact information will never be sold or provided to third parties.

Woo! You are so welcome in our world :)

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THINK Coaching & Hypnotherapy
ABN 71 420 283 747

info@thinkcoaching.online
Call 0407 671 039

THINK Coaching & Hypnotherapy welcomes all humans regardless of race, religion, sexuality, gender identity or vaccination status! All services are offered online. Face-to-face sessions are available by arrangement only.

In the spirit of reconciliation, we acknowledge the Traditional Custodians of Country throughout Australia and their connections to land, sea and community. We pay our respects to elders past and present and extend that respect to all Australian Aboriginal and Torres Strait Islander peoples today.