RTT Hypnotheropy
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Client Intake Form
Client Intake Form
Name
Date of Birth
Preferred name
Relationship status
Email
Phone number
Occupation
Address
Post Code
Doctor's Detail
Name of your doctor?
Address of your Doctor
Doctor's Post Code
Medicatin being taken
Health Problems (Past & Current)
Why you seeeking therapy?
From the list below circle/tick/highlight your areas of concern
Addictions
Drinking
Smoking
Drugs
Gambling
Compulsive Behaviour
Anxiety/Depression
Trauma/Abuse
Stress
Fears/Phobias
Panic Attacks
PTSD/CPTSD
Childhood Problems/Trauma
Eating Problems
Food/Diet
Weight Problems
Anorexia
Bulimia
Exercise
Confidence
Self Esteem
Motivation
Achieving Goals
Procrastination
Public Speaking
Concentration
Exams
Memory
Sleep Problems/Insomnia
Tiredness
Pain
Mobility
Hearing
Sight/Vision
Skin Problems
Autoimmune Disorders
I confirm that I have been advised by The Practitioner of the scope of the therapies that she provides and give my full consent to receiving therapy sessions
I confirm that I have been advised by The Practitioner of the scope of the therapies that she provides and give my full consent to receiving therapy sessions
I confirm that I read and accept all terms and conditions as stated in Disclosure Form
I confirm that I read and accept all terms and conditions as stated in Disclosure Form
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