Pre consultation call questionnaire

Questionnaire pre-consultation call
Name and surname*

NameSurname
Sex*

MaleFemale
Residence*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Do you suffer from a chronic health condition?*

YesNo
If yes, explain it here.
Are you on any kind of medication?*

YesNo
If yes, please indicate it here.
Do you suffer from epilepsy or bipolarism?*

YesNo
Have you ever tried hypnosis or hypnotherapy?*

YesNo
Have you ever tried meditation?*

YesNo
Have you seen in the past or are you seeing right now a psychologist / psychotherapist / psychiatrist or any other medical figure?*

YesNo
Why are you interested in working with me?*
Describe the issues and problems most important to you that you would want to work on with me.*
How much are you willing to put effort into your healing and transformation?*

1

2

3

4

5

6

7

8

9

10

1 is Not ready, 10 is Super ready
By selecting the boxes, you are confirming that you have read them and that you agree with them.*
I agree:
By submitting this form, I confirm that the information provided is accurate and truthful. I understand that this information will be used to assess whether the RTT method and Rachele are suitable for me. By submitting this form, I agree to receive an email with all the details of the offer and the cost of the RTT sessions, as well as the link to book a free consultation call with Rachele.
Please verify you are human*
Should be Empty:

Questionnaire pre-consultation call