Rapid Transformational Therapy Intake form
GETTING TO KNOW YOU.

This form is an opportunity for you to share as much as you want about you with me and for me to find out what you need/ what you would like to work on and how I can help you best.
Please note that the fields marked with an asterisk are required fields.

Email address *
PERSONAL DETAILS
First name *
Your answer
Last name *
Your answer
Phone *
Your answer
Address *
Your answer
Marital status
Date Of Birth
MM
/
DD
/
YYYY
Occupation
Your answer
MEDICAL INFO
This section is particularly helpful/ important if you would like to address a physical/ medical issue.
Doctor's name
Your answer
Date of last check up
MM
/
DD
/
YYYY
Current medications
Your answer
YOUR AREAS OF FOCUS
You can pick as many as you feel are relevant.
From the list below select the areas that concern you *
Required
If you had to choose ONE, MOST IMPORTANT ISSUE to focus on in your session, what would it be and why? *
For example: "Stress because it keeps me from focusing on my work, making money, keeps me up at night and stops me from being present with my friends and family. Etc..."
Your answer
If you no longer struggled with this issue, how would it impact your life? *
Please be specific; the words and phrases you share are essential to the new beliefs you create. For example, talk about how would it impact your work? Your relationships? Your health? Your finances?
Your answer
What's your ultimate desire? *
What is your big dream and desire for your life? To feel free and financially secure? To travel the world with your partner? Don't hold back!
Your answer
Additional notes
Please use the space below to add anything else that you think is relevant (either with regards to what you'd like to work on or the results you are after).
Your answer
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