RTT Intake FormPersonal Details What is your full name (First & Last)? What do you prefer to be called? (Enter nickname), if any. Email Address: What is your Phone number? Age Gender Emergency Contact Name / Relationship to You Emergency Contact Phone Number Marital/Relationship Status Single Married Separated Divorced Committed Relationship OtherHealth If you are currently under the supervision of a doctor for the issue being addressed with hypnosis, please include your doctor's name and contact information. Please give a brief history of any health issues, including known health issues that may run in your family. Are you currently on any medications? (Please list) Are you currently or have you ever been treated by a therapist?Family Briefly describe your family. Number of years with your partner, number of children and their ages, siblings and birth order. List any relevant information about your family that may impact the issue we are working on.About YouDo you or have you in the past struggled with: Addictions Drinking Smoking Drugs Gambling Career Issues Concentration Driving skills Taking Exams Interview Skills Memory Nerves Public Speaking Anxiety Fears Guilt Panic Attacks Phobias Relaxation Stress Pain Control Hair Growth Hearing Mobility Sight/Vision Skin Problems Sleep Problems Eating Problems Anorexia Bulimia Exercise Food/Diet Weight Issues Relationships Childhood Problems Sexual Problems Fertility IVF Achieving Goals Confidence Depression Motivation Self Esteem Procrastination Other Please describe the issue you would like to work on Briefly describe how this issue has impacted your life? Example -"Anxiety keeps me from focusing on my work. Worrying about making money keeps me up at night and stops me from being present with my spouse", etc. When did the issue start? What was going on in your life at that time? What change took place in your life at that time? If you no longer struggled with this issue, what would you do that you cannot do now? Be specific. How would it impact your work? Your relationships? Your health? Your finances?? If you could wave a magic wand and instantly have the outcome you want (relating to the issue), what would that outcome be? On a scale of 1-10, how ready are you to let go of this issue? Have you ever been Hypnotized? Yes No Is there anything else you'd like me to know before our session? Questions, Concerns, or Additional Info you'd like to shareBy checking this box and typing my name below, I am electronically signing this form and I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. Sign Here
