Intake Form

Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Health problems and medications

Please ensure that you have discussed with your healthcare provider on this session.

Select the areas of concern:

Addictions and Compulsive behaviorsEmotional & Mental Well-being (Anxiety, Stress, Fears, Phobias, Panick Attacks, Guilt)Eating and Body Image and Weight (Eating Problems, Anorexia, Bulimia, Exercise, Food/Diets)Career and Mind Performance & Skills (Concentration, Public Speaking, Exams, Memory, Driving, Interview Skills)Physical Health & Body Function (Pain control, Hearing, Sight/Vision, Sleep problems)Relationships and Personal Life (Childhood problems, Relationships, Rejection, Grief)

1. What is the main issue you would like to work on during our session?*

2. When did this issue begin and how long have you been experiencing it?*

3. How does this issue affect your daily life? Please describe how this impacts you physically, mentally, emotionally, socially, financially*

4. What beliefs do you currently hold about yourself in relation to this issue?(Examples: “I’m not good enough,” “I can’t change,” “I feel stuck.”)*

5. What is your desired outcome for the session? (What would you like to achieve or experience as a result of this session?)*

6. Imagine the issue is completely gone — your ideal life. If I were to create a personalized transformation recording just for you, what would you want it to include? Please describe the following in clear detail: How do you see yourself? What would you like to see around you? What would you like to hear? (Praises, affirmations, supportive words. How would you like to feel? What experiences would you like to have? (Describe your “after” life vividly — this helps shape your mind’s transformation.)*

Thank you for your time and commitment to your transformation.
I look forward to guiding you through your RTT session.

LivXtraordinary

RTT INTAKE FORM