Anahata Flow States Healing Center

Anahata Flow States Healing Center

Intake & Consultation Form
I am delighted to be working with you to help you achieve your transformational goals.

To find out more about you and to help clarify what you would like to work on during our time together, please complete this form with some of your personal information. The information you provide will tell me a little about you, your lifestyle, what you want to achieve, and what is holding you back. It will also help me to tailor the coaching program to meet your needs and desired outcomes.

Please answer the questions honestly and to the best of your ability, and note that all the information you provide is completely confidential.
Client's Full Name:

First NameLast Name
Email
example@example.com
What do you want to achieve while working with me through Rapid Transformational Therapy, Coaching & or Life Force Energy Healing?
Why is that important to you?
What would achieving this aspirational goal do for you?
How would it make your life different from the way it is now?
What support would you need to help you take action?
Please Check Areas of Concern Below
What is the Presenting Problem?
What are the Symptoms, Triggers & Habits of this problem?
What was your childhood like?
How was your relationship with Mom, Dad &/or other Caregivers?
Were there any notable traumatic incidents?
Were there any substance abuse issues with Caregivers while growing up?
Did you experience bullying?
Do you have any siblings and if so what order are you in the birth order?
Please describe in as much detail as you can, In your mind's eye what will your life look like without this problem? What will you be seeing, Feeling and experiencing?
On a Scale of 1-10 with 1 being the Least motivated & 10 being the MOST motivated, how motivated are you to make this change?
DISCLAIMER AND DECLARATION
Scope of Coaching

Rapid Transformational Coaching® (RTC®) integrates the effectiveness of Rapid Transformational Therapy® (RTT®), which is a unique, powerful and comprehensive, solution-based approach pioneered by Marisa Peer, one of the world’s most respected therapists. The information, techniques and methods provided by the coach are not intended as substitutes for any professional advice such as legal, mental, medical, or other qualified, professional advice. If you are under medical care for ANY condition, do NOT make adjustments to ANY prescribed medication without the approval of your doctor. If in any doubt, you should seek your doctor’s advice.

Please sign below confirming you have read and agree to the above.
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Privacy, Confidentiality and Data Protection

To protect your privacy, all client data is kept strictly confidential and will be stored in accordance with the General Data Protection Regulation (GDPR)/applicable Data Privacy laws. All information is completely confidential always, unless permission is given otherwise. You hereby consent that the

Coach may release information to a relevant individual or agency if it has been determined that a child or adult is at risk of abuse or is currently being abused; or if you, as a client, are an imminent danger to yourself or others; or if a subpoena of records or any other requirement to share information by law has been requested.

Please sign below confirming you have read the above and agree.
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Name

First NameLast Name
Coach Name:

Dawn Aldredge

dawn.aldredge1@gmail.com

908-380-0308

Anahata Flow States Healing Center

www.anahataflowstateshealing.com
Type a question
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Anahata Flow States Healing Center

Please Check Areas of Concern Below