Simon Cook
Rapid Transformational Therapy (RTT)
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Intake Form

Intake Form

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Surname:

Forename

Phone:

Age

Address:

Marital/Relationship status:

Email:

Occupation:

Emergency Contact Name:

Emergency Contact Telephone:

Doctor’s name and address:

Are you currently being treated for any conditions?

Do you have any ongoing health issues?

What medications are you taking?

Addictions

Drinking

Smoking

Drugs

Gambling

Compulsive

Behaviour

Anxiety

Stress

Fears

Phobias

Panic Attacks

Guilt

Relaxation

Eating Problems

Food /Diet

Weight Problems

Anorexia

Bulimia

Exercise

Depression

Confidence

Self Esteem

Motivation

Achieving Goals

Procrastination

Career issues

Interview Skills

Nerves

Public Speaking

Concentration

Exams

Memory

Driving Skills

Sexual Problems

Fertility

IVF

Conception

Pregnancy

Birth

Pain Control

Hearing

Sight/Vision

Mobility

Skin Problems

Hair Growth

Relationships

Childhood Problems

Sleep Problems

Is there anything else that is not listed above?

Have you ever been hypnotised before? If not, is there anything that concerns you about it?

Have you tried other treatments to help with your issue(s)? If so, what were they?

How committed are you to change on a scale of 1 to 10? (1 is not ready at all and 10 is completely devoted)

1

2

3

4

5

6

7

8

9

10

1. In your own words, what is/are the issue(s) that you want RTT to change?

2. Please describe any symptoms or triggers regarding the above issue(s)

3. Please summarise your childhood and anything you feel would be helpful for me to know

If the issue(s) could be fixed tomorrow, what would you want me to do?

What would your life be like without this issue?

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What is Rapid Transformational Therapy (RTT)

What Happens at Hypnotic Change?

What Can I Help With?

Pricing

Hypnotic Change. Look at your past and change your future.

You don’t know how I could help until you ask, so just be brave and take that first step on the road to change. I look forward to hearing from you.

Get In Touch

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GET IN TOUCH

Hypnotic Change. Look at your past and change your future.

contact@hypnotic-change.co.uk

07773 052472

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All Rights Reserved | Hypnotic Change by Simon Cook

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