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RTT Client Intake Form
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Step
1
of 3
Name
*
First
Last
how Occupation much
Preferred Name
*
Email
*
Phone
Occupation
Relationship Status
Medications being taken:
Health problems past and current
Date of last check-up
Next
Mark all your areas of concern
Addictions
Drinking
Smoking
Drugs
Gambling
Compulsive Behaviour
Eating Problems
Food/Diet
Weight Problems
Anorexia
Bulimia
Exercise
Depression
Confidence
Self Esteem
Motivation
Achieving Goals
Procrastination
Relationships
Childhood Problems
Sleep Problems
Career Issues
Interview Skills
Nerves
Public Speaking
Concentration
Exams
Memory
Driving Skills
Pain Control
Hearing
Sight/Vision
Mobility
Skin Problems
Hair Growth
Anxiety
Stress
Fears
Phobias
Panic Attacks
Guilt
Relaxation
Sexual Problems
Fertility
IVF
Conception
Pregnancy
Birth
Next
Please answer these questions and add more information if needed:
Tell me what you want to work on How long have you had it? What triggered it? Have you tried to solve it before?
Tell me about your symptoms and triggers How/when does it affect you? How does it make you feel? What is going on in you head?
From 1-10 how much does this bother you? (1=not much, 10=very much)
How was your Childhood Parents, siblings, friends, school, life? Feelings? Traumas?
Magic wand If I could grant you one wish, what would it be?
Tell me how life will be without your issue? How will you feel? Who will you be? What will you do that you can’t/don’t do today? How will you see life, your relationships? How would a perfect ordinary day look like?
How will you know that you don’t have this issue anymore?
Submit