Client Intake Form
Rapid Transformation Therapy
Personal Details
Surname
*
Forename
*
Preferred Name
*
Preferred Pronouns (choose all that apply)
*
She/Her
He/Him
They/Them
Rather not say
Other
Date of Birth
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Month
-
Day
Year
Date
Age
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Address (#, Villa/Apt, Building, Street, Area, City)
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Marital/Relationship Status
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Email Address
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Telephone
*
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Area Code
Phone Number
Occupation
*
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Health Details
Doctor's Name
*
Doctor's Address (#/Building, Street, Area)
Date of Last Check Up
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Month
-
Day
Year
Date Picker Icon
Medications Being Taken
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Any Health Problems (past & current, physical & non-physical)
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Areas of Concern (choose all that apply)
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Addictions
Drinking
Smoking
Drugs
Gambling
Compulsive Behaviour
Anxiety
Stress
Fears
Phobias
Panic Attacks
Guilt
Relaxation
Eating Problems
Food/Diet
Weight Problems
Anorexia
Bulimia
Exercise
Depression
Confidence
Self-Esteem
Motivation
Achieving Goals
Procrastination
Career Issues
Interview Skills
Nerves
Public Speaking
Concentration
Exams
Memory
Driving Skills
Sexual Problems
Fertility
IVF
Conception
Pregnancy
Birth
Pain Control
Hearing
Sight/Vision
Mobility
Skin Problems
Hair Growth
Relationships
Childhood Problems
Sleep Problems
Other
Have you received hypnosis before?
*
Do you meditate?
Yes
No
If yes, how often?
What issue would you specifically like to address during our session(s)?
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On a scale of 1-10, how much is this issue affecting your life right now?
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Not at all
1
2
3
4
5
6
7
8
9
Constantly
10
1 is Not at all, 10 is Constantly
What symptoms are you experiencing related to this issue?
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What triggers this issue and what habits have you formed related to your issue?
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How old were you when this issue began?
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If I had a magic wand and could grant you one wish during your session, what would that be?
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(Please relate your answer to this specific issue).
Once your wish is granted, how will you feel? What would life be like?
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(Focus on what you want to FEEL instead of what you don't want to feel. Remember, you no longer have whatever is blocking you today. Please be as specific and descriptive as possible).
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