RTT Intake Form 🔒
Please complete in full
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Full Name *
Preferred name to use in hypnosis *
Date of Birth *
MM
/
DD
/
YYYY
Address *
Occupation *
Mobile/ Cell Number *
Doctor's name and address *
Health Issues (current and past) and Current Medications *
What change do you desire from this session (in less than two sentences) *
How committed are you to making this change now - score out of 10. (1 not ready - 10 fully ready) *
From the list below please tick all areas of concern *
Required
Do you have suicidal thoughts? Past or current? *
Anything else you feel relevant to share? *
Please tick to agree to RTT Terms and Conditions (link below) *
Required
Please tick to confirm you agree to the Liability Waiver (link below) *
Required
Emergency contact name and number *
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This form was created inside of Energy Gardener.