Rtt Client Intake Form

Name

First NameLast Name

Age

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Email

example@example.com

Marital / Relationship status

Occupation

Emergency Contact

Name/RelationshipContact

Are you currently receiving any treatment from a Doctor or other Practitioner? If yes give brief details?

Are you currently taking any medication? If yes please give details?

What are you wanting to address & achieve from your RTT session? Please be as specific as possible.

If you were free from the issue you present with, what would it mean for you? How would your life be different?

If I were to wave a magic wand, what is one thing you would have me change, right now?

History: Is there any illness, distress, or other concern in your history that is relevant to your session or that you think we should know about? Please give details:

How high is your motivation to act & achieve the change you desire ? From a scale of 1-10. 10 being strongest motivation.

Please select the areas that concern you:

Any other concerns not listed:

DISCLAIMER

The information, techniques, methods and recommendations by Jane Mellor are not intended as a substitute for the diagnosis and care of a qualified doctor, psychiatrist or psychologist. If you use hypnosis and are under medical care for any condition, do not make any adjustments to any prescribed medication without the approval of your doctor. If in any doubt, you should seek medical advice.

By participating in a Rapid Transformational Therapy session you are accepting full responsibility for your own emotional and physical well-being and are agreeing that Jane Mellor holds no liability whatsoever for any potential outcome.

By signing this form, I consent that Jane Mellor may release information to a specific individual or agency if it has been determined that a child or elder is at risk of or is currently being abused; If I, as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested.

Jane Mellor is a member of IICT & carries full Professional Indemnity and Public Liability insurance with BMS Risk Solutions

DECLARATION

The information I have given here is to the best of my knowledge, full and correct.

I undertake therapy on the understanding that it is a collaberative process, and that progress depends in part upon my own motivation and participation, including my willingness and desire to affect the changes inside of myself.

I agree to take part in all sesssions free from drugs & alcohol.

I understand that if I am epileptic or suffer from a psychotic illness it is not recommended that I undergo hypnotherapy. I hereby agree that by signing this form that I do not currently suffer from these disorders.

I can confirm that I have read the above disclaimer and understand the process of RTT and hypnotherapy and accept these terms and conditions.

Signature

Date

Jane Mellor Rtt, C.Hyp

Rapid Transformational Therapist

Certified Hypnotherapist

Contact: janemellor@hotmail.com.au