[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?*

Search EngineLinkedinInstagramTwitterFacebookFriends' Social MediaRTT Online DirectoryRecommendation by a friendOther:
Personal Details
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Age*
Marital Status*

SingleIn a RelationshipEngagedMarriedSeparatedDivorcedWidowed
Do you have kids? if yes, how many, how old are they and what are their names?*
Current Occupation*
Phone Number*
Do you mind connecting 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*

AddictionsAnxietyEating ProblemsDepressionDrinkingStressDiet ProblemsConfidenceSmokingFearsAnorexiaSelf-esteemDrugsPhobiasBulimiaMotivationChildhood IssuesPanic AttacksExerciseAchieving GoalsMemoryGuiltNail BitingProcrastinationCareer IssuesSexual ProblemsPain ControlRelationshipsInterview SkillsFertilityHearingExamsNervesIVFSight/VisionSleep ProblemsPublic SpeakingConceptionMobilityDriving SkillsConcentrationPregnancySkin ProblemsPost Birth IssuesHair GrowthGamblingCompulsive Behavior
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