RTT™ Intake form
Please fill out this form so I can better prepare for the RTT session with you.
Third-party emergency contact number
Date of birth
Describe briefly your current problem/situation?
What do you expect from the RTT session?
Health problems (FROM THE LIST BELOW TICK THE AREAS THAT CONCERN YOU)
RTT is not meant to be a substitute for the advice or care of a qualified medical professional. All information presented or recommended byJustyna Falkowska is meant for educational purposes only. If you unsure about whether or not you should take part in an RTT session, please consult your general practitioner first.To protect your privacy, all client data is kept strictly confidential. Before taking part in your RTT session(s), please ensure: 1. That you do not suffer from epilepsy. 2. That you will be free from the influence of drugs or alcohol during thecourse of your session. 3. That you provide me with the correct address of your online location. 4. That the environment around you is safe and will remain distraction free. 5. That you provide me with a phone number or other means of communication to contact you with in the case of a technology failure. 6. That you provide me with a third-party emergency contact number. I confirm that I have read and accept the following Terms & Conditions.
Yes! I undestand!
I understand that I have to play an active role in the successful outcome of my session(s). I must be motivated to change and follow through with the process.
Yes! I understand!
Date of filling out the RTT Intake Form
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