Rapid Transformation Therapy
Registration Form
Full Name
*
First Name
Last Name
Your preferred name?
*
Gender
*
Please Select
Male
Female
N/A
What's your date of birth?
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Month
-
Day
Year
Date
Contact Number
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Country Code
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Area Code
Phone Number
Email Address
*
example@example.com
Emergency Details
Name
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First Name
Last Name
Phone Number
*
-
Country Code
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Area Code
Phone Number
HEALTH
Have you been diagnosed with any medical conditions? If so, please elaborate
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Are you currently taking any medication or undergoing any treatment?
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Yes
No
If so, please describe/list them.
Do you use any kind of illegal drugs or have you ever used them?
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
AREAS OF CONCERN
Please select any and all relevant areas.
Compulsive Behaviour and Addictions
Compulsive Behaviour
Smoking
Drinking
Drugs
Gambling
Porn
Social Media/Phone Use
Other
Are you struggling with any of these?
Anxiety
Stress
Depression
Fears
Panic Attacks
Phobias
Grief
Guilt
Nerves
Childhood/past problems
PTSD
Other
Have you experienced difficulties with any of these?
Motivation
Concentration and Focus
Self-Esteem
Confidence
Memory
Relaxation
Achieving Goals
Procrastination
Money blocks
Career Issues
Interview skills
Public Speaking
Have you been affected by any of these problems?
Relationships
Sexual problems
Infertility and pregnancy
Hearing
Sight/vision
Hair growth
Skin problems
Headaches
Mobility
Sleep problems
Other
In one phrase or word specify what is the problem you want to work on?
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When did the problem start affecting you?
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In your own words describe how does problem affect your life and/or your health on daily basis or in a long run?
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Please indicate how often or how intense symptoms are where relevant. Specify any triggers or related habits.
Tell me more about your close family (parents/siblings and your relationship with them) and childhood. Is there any relevant family history to the problem?
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If you could imagine your life without the problem how would look like? Please include as much detail as possible.
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Have you had hypnotherapy before?
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Yes
No
Whether you had it or not before, do you have any concerns or worries about this type of therapy?
On a scale 1 to 10, where 10 means totally and fully committed, how committed are you to address the issue and make a change in your life?
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Is there anything else you would like to add that you think it is relevant/important to note.
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