RTT Intake and Consultation Form

PERSONAL DETAILS:

HEALTH:

FROM THE LIST BELOW HIGHLIGHT/TICK YOUR AREAS OF CONCERN:

Other – please feel free to add any areas of concern not covered by the above.  This will help me to understand you better so that I am better able to help you to achieve your goals.

CLIENT QUESTIONNAIRE 

Please provide a few more details of what is the most important issue I can help you with at the moment?

On a scale on 1 to 10 how much do you want to remove this issue? 

What are the main symptoms or triggers you experience?

How do these symptoms get in the way of your life?

Any relevant childhood issues that I should be aware of?

CONFIDENTIALITY

Please note that all information supplied is treated with confidentiality and in line with GDPR standards. 

PERMISSION TO RECORD 

(please tick as appropriate and sign below)

STUDENT RTT PRACTITIONER NAME:    

CONTACT DETAILS:   

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 collaborative process, and that progress depends in part upon my own motivation and participation.

I understand that this session is with a Trainee Rapid Transformational Therapy Practitioner and not with a licenced medical professional. 

I can confirm that I do not have a diagnosed condition of bipolar or schizophrenia and I have supplied details of medical conditions and medication as requested in the relevant part of the form. 

I understand that I will receive a transformation recording (up to three days after the session) that I will listen to for 21 to 30 consecutive days.