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Blissful Release Now: RTT INTAKE FORM
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Email
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Untitled Title
Full Name
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Preferred Name
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Phone
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Email
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Age
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Emergency Contact Name & Phone Number
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Thoughts or Notes you want me to know
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Diagnosed Health Conditions
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Date of your last doctor visit
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YYYY
Current Medications
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Areas of Concern (Check all that apply):
Addictions
Drinking
Gambling
Drugs
Anxiety
Compulsive Behaviors'
Depression
Stress
Fear
Performance Anxiety
Phobias
Guilt
Panic Attacks
Relaxation
Career Issues
Interview Skills
Nervousness
Public Speaking
Concentration
Exams
Memory
Eating Problems
Food/Diet
Weight Problems
Anorexia
Bulimia
Exercise
Relationships
Sexual Problems
Fertility
Pain Control
Hearing
Sight/Vision
Mobility
Skin Problems
Hair Growth
Confidence
Self-Esteem
Motivation
Achieving Goals
Procrastination
Insomnia
Other Sleep Issues
What is the main area you would like to focus on in our session? What have been or are Symptoms/Triggers/Habits (Describe your symptoms, triggers, and habits of the issues you want to change in your life)
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Childhood(Describe your childhood in general terms) What was your relationship with your parents? What did they teach you about being lovable? Did you have to strive/work hard or be 'good/perfect' to be loved? How did your parents talk to you?
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If you could wave a magic wand and get what you really want, what do you want the most?
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Life Without the Problem – THIS IS IMPORTANT - what would your life look like without the problem - (use strong, visual words). Describe in detail what you would be feeling, seeing, and hearing. What would a day look like? What would you be telling yourself? What would you be feeling?
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Has anyone else in your life made you feel bad about yourself? What does this make you believe about yourself?
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How has this issue affected you in your life?
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What is your ultimate desire? What is your big dream for your life?
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Have you ever had hypnosis before?
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No
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If yes, how helpful was it for you?
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How did you hear of Tracy? If referred, please let me know by whom.
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By Checking Here: After our session, I am fully committed to listening to the recording for at least 30 days, once or twice daily, to ensure optimal results. I acknowledge that 60% of the desired change and healing can be achieved through the session, and 40% is my commitment to change.
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The above information has been provided to the best of my knowledge. I agree to the Terms & Conditions and Privacy Policy that can be found
on the Liability Waiver form
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www.blissfulreleasenow.com
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