[Adults] RTT Intake & Consultation Form

[Adults] RTT Intake and Consultation Form

Rania Kassab Chakhtoura | Certified Hypnotherapist | RTT
Email
example@example.com
Today's Date

MonthDayYear
Date
How did you hear about me?

Other:
Personal Details
Name

First NameLast Name
Date of Birth

DayMonthYear
Age
Marital Status
Do you have kids? if yes, how many, how old are they and what are their names?
Current Occupation
Phone Number
Can I connect with you over Whatsapp?
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Areas of Concern
From the list below select the area of your concern

Other
Which of the above issues (in case you highlighted more than one) is the most important one to change?
Health
Doctor’s name and Address:
Date of Last Check up
Medications being taken, if any
Health-Mental-Psychological Problems [past & current], if any:
Emergency Contact Name
Emergency Contact Phone Number
Emergency Contact Relationship to you
Challenge
Describe briefly the issue that you would like to fix
Symptoms/ Triggers/Habits - Describe the symptoms of the issue, when is it triggered? What are the habits established due to the issue?
Childhood - Any specific thing that you would like to share about your childhood? Family, Siblings, Challenges, Problems...? How supportive is your family?
What do you want out of this session? If I have a magic wand, what do you like to change in your life? Please elaborate as much as you can.
Life Without the Problem - Can you please describe life without the problem that you want to solve? Please elaborate as much as you can OR Describe a typical day without the problem currently being faced (Morning- Night).
How motivated are you to work on this/change this?

1

2

3

4

5

6

7

8

9

10

1 is , 10 is
Should be Empty:

[Adults] RTT Intake and Consultation Form

Personal Details

Areas of Concern

Health

Challenge