Rapid Transformational Therapy Intake
Welcome to the beginning of your Rapid Transformational journey!
     
      I am so excited that you have chosen to experience this powerfully healing process. The following  questionnaire is designed to capture important information before we begin working together. Please fill it out to the best of your ability as these details will help me better understand and serve you during our time together. It will most likely take you about ten minutes to fill out.

                                                                                                                     Warmly,
                                                                                                                       Frank                  
                                                                                                        Mind Alchemy New York
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First and Last name *
Name you like to be called *
Date of Birth *
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Phone Number *
Emergency Contact/Phone Number *
Occupation *
Are you currently under a Doctor’s care for any issue? If so, for what and how long? *
Current medications *
From the list below select all that concern you : *
Required
Please expand on any selection in previous section if you have any specific concerns. *
Tell me how this issue impacts your life. *
On a scale of 1-10, how much would you say this issue is affecting your everyday life? 10 being this issue has altered your life and affects it every day. *
When did the issue(s) start? What was going on in your life at that time? What change(s) took place in your life at that time? *
What triggers the issue(s)? *
Please describe the symptoms you experience when the issue is present. What you think/feel/body sensations (if applicable). *
What treatments/strategies have you tried to overcome this issue(s)? *
Looking ahead: If you NO longer struggled with this issue, what would you do that you can’t do now? BE SPECIFIC- How would being free from the issue impact your daily life, social life, relationships, health, finances? What would you feel? *
Briefly describe your family. Number of years with your partner, number of children & their ages, siblings & birth order. List any relevant information about your family that may impact the issue we are working on. *
Please provide any relevant (from your point of view) details about your childhood (age 0-10) including but not limited to the relationships between you and your immediate family. Did you have any adverse childhood experiences? What were they? *
What exactly you would like to let go of in this session? *
If I could wave a magic wand and do ONE thing for you, what would you wish for? What do you want to transform in this session? *
How do you cope with stress? Please select what describes your patterns the best, and if it's a combination of two please indicate them in the "other" section: *
TERMS & CONDITIONS
Please read these Terms and Conditions (“Terms”, “Terms and Conditions”) carefully before using the www.mindalchemynewyork.com website (the “Service”) operated by Frank Caiati (“us”, “we”, or “our”).

Your access to and use of the Service is conditioned on your acceptance of and compliance with these Terms. These Terms apply to all visitors, users and others who access or use the Service.
By accessing or using the Service you agree to be bound by these Terms. If you disagree with any part of the terms then you may not access the Service.

"RTT" refers to Rapid Transformational Therapy.

Status and Scope of Practice
Frank Caiati is a Rapid Transformational Therapy Practitioner. Rapid Transformational Therapy is a technique that utilizes hypnosis to gain insight into one's mind and enable one to make changes in their mind. I do not diagnose or treat disease and I am not a physician. These sessions are not a substitute for diagnosis or treatment from a qualified health practitioner for illnesses, injuries, or other medical conditions.

Fees and Outcomes
Individual results cannot be guaranteed.
You are responsible for your own health and wellbeing. You must take all the advice, steps and measures recommended to obtain the best result.
Fees are non-refundable post-treatment and are payable in advance to confirm your booking time.

Cancellation Policy
Cancellation for sessions require a 48 hour notice period. We reserve the right to charge for cancellations with less than 48 hours notice.

Limitation of Damages
In no event will Frank Caiati  or any of his affiliates be liable for any consequential, indirect, incidental, or special damage whatsoever, including without limitation damages for the loss of profits, business interruption, loss of or unauthorized access to information, and the like, even in the event of fault, breach of contract or breach of warranty, and even if Frank Caiati has been advised of the possibility of such damages.

Medical Concerns, Indemnity and Disclaimer
Caution: Epileptics, individuals diagnosed with psychotic illness and patients who are self-harming (without a doctor's note) and will not be seen or treated. 
You must declare all medicines being taken on your intake form. DO NOT make any alterations to your prescribed medicine without discussing with your Physician / GP beforehand.
The information, techniques, methods and recommendations by Frank Caiati are not intended to substitute for the diagnosis and care of a qualified physician / GP nor to encourage the treatment of illness by persons not recognizably qualified. If you use hypnosis and are under medical care for ANY condition, do not make ANY adjustments to ANY prescribed medication without the approval of your doctor. If in any doubt you should seek your GPs advice.
You are responsible for your own health and well being and accept all outcomes of the treatment as your own responsibility. We accept no responsibilities whatsoever. Under no circumstances including but not limited to negligence shall Frank Caiati or any of his staff members be liable for any special or consequential damages in any way whatsoever now or in the future that results from the use of or the inability to use hypnosis / advanced hypnosis techniques / hypnotherapy or any other therapies.
The information given is not intended to constitute medical advice. Always consult your physician before changing medications and when evaluating treatment alternatives.
Frank Caiati does not accept responsibility for any loss, damage or expense resulting from RTT session and the use of information learned. You, or my representative(s), agree to full release and hold Frank Caiati harmless from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with your session(s).

Confidentiality/Client Rights
Your experiences during our sessions are confidential, and you have a right to view your files upon written request. Confidentiality is subject to the following exceptions:
-You may instruct me to release information to other health care practitioners in writing.
-I may release information if legally obligated or reasonably allowed to do so (including circumstances where there is clear and imminent danger to yourself or another person).
-Your confidentiality is always subject to the usual exclusions dictated by local laws and regulations.
By agreeing to these terms, you confirm that: *
Required
RTT Waiver Form
By checking the box below I hereby release Frank Caiati and Mind Alchemy New York LLC from any liability or claims that could be made against him concerning my mental and/or physical well-being during the work that has been outlined and agreed upon (now and in the future) by filling out this form.

I understand that Frank Caiati and Mind Alchemy New York LLC is not a licensed physician, psychologist, or medical practitioner of any kind and that hypnosis should not be considered a replacement for the advice and/or services, of a psychiatrist, psychologist, psychotherapist, or doctor. I give Frank Caiati and Mind Alchemy New York LLC full permission to hypnotize me and to use Rapid Transformational Therapy knowing that by participating fully in the process and by listening to my personalized recording for 21 days I play an important role in my overall success.

I understand that although Rapid Transformational Therapy has in incredibly high success rate, Frank Caiati and Mind Alchemy New York LLC cannot and does not guarantee results since my own personal success depends on many factors that Frank Caiati and Mind Alchemy New York LLC  has no control over, including my willingness and desire to affect the changes inside of myself. Except in the case of gross negligence or malpractice, I or my representative(s) agree to full release and hold
harmless Frank Caiati and Mind Alchemy New York from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s).

I give Frank Caiati and Mind Alchemy New York LLC full permission to make audio recordings that may include my voice. I understand that if a recording (or recordings) are made during or after my session(s) Frank Caiati and Mind Alchemy New York LLC retains full copyright over any forms of media that may be produced for or distributed to me.

For in-person sessions, I hereby grant permission to Frank Caiati and Mind Alchemy New York LLC to respectfully lift my arm, touch my shoulder, lightly touch my eye-lids, tap my forehead or rock my head in order to help facilitate the deepening process.

By signing this form, I consent that Frank Caiati and Mind Alchemy New York LLC may release information to a specific individual or agency if it has been determined that a child or elder is at risk or is currently being abused; if I, as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested. I understand that, at any time, Frank Caiati and Mind Alchemy New York LLC may discuss aspects of my case with other colleagues keeping my full name, identity completely confidential always unless I have given permission otherwise.

I understand that Frank Caiati, c/o Mind Alchemy New York LLC, is insured under Energy Medicine Professional Insurance.

My questions have been answered to my satisfaction regarding my Frank Caiati and Mind Alchemy New York's background, an RTT session, and what I might expect from this session.

I fully consent to use the services offered by Frank Caiati and Mind Alchemy New York by signing below:
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My digital signature: *
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