Preferred Name (Required)
(Required) Health & Medical History Any history of seizures or epilepsy? (Required) Any history of psychosis or psychotic episodes? (Required) What are your main areas of concern? Tick from any and all of the areas of concern (Required) Symptoms, Triggers, Habits Thinking about the main area you would like to focus on, what are the symptoms, triggers and habits that show up for you with this concern? (Required) Childhood Please describe your childhood, family structure / parents / siblings. Any major events that occurred? What your relationship was like with your parents and your siblings? (Required) What You Want If I could wave a magic wand and give you exactly what you want, describe what that would be in as much detail as possible. (Required) Life Without The Problem Now imagine your life without this problem. What does it look like and specifically what does it feel like? Go into as much specific detail as possible here please. (Required) Terms Of Agreement
Rapid Transformational Therapy (RTT) is a very unique method that typically requires 1 to 3 sessions to resolve most deeply-rooted issues. 2) RTT uses hypnosis, which is a completely safe and relaxing process where you will remain in control throughout the duration of your session. 3) During RTT, you will be regressed back to several memories in order to uncover where, when, how and why you developed the presenting issue. The insights from this will help you to gain deeper understanding of the root, cause, and reason for the presenting issue. 4) It's important to understand that you play an active role in the successful outcome of your session(s). You must be motivated and committed to change, trust your Therapist, and follow through with this process as guided by your Therapist, Amanda Cremonini. 5) You will need to actively participate by listening to the Transformation Recording for at least 21 days after our session, which is an essential part of re-coding your mind and embedding positive new beliefs. 6) RTT is not intended to be a substitute for advice or care from a qualified medical professional. 7) To protect your privacy, all client data is kept strictly confidential. 8) Before taking part in your RTT session(s), please ensure: * That you do not suffer from epilepsy. * That you will be free from the influence of drugs or alcohol during the course of your session. * If your session is online, the environment around you is safe and that you will not be disturbed/distracted. * That you provide me with a phone number or other ways of communication in case of a technology failure for online sessions. * That you provide me with a third- party emergency contact number. 8) If you cannot attend your scheduled session, you agree to give 24 hours notice. If you fail to show for your booked session without giving the required notice period, the session is still payable.
Liability I hereby release Amanda Cremonini, from any liability or claims that could be made against her 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. Scope of Practice I understand that Amanda Cremonini is not a licensed physician, psychologist, or medical practitioner of any kind and that hypnotherapy should not be considered a replacement for the advice and/or services, of a psychiatrist, psychologist, psychotherapist, or doctor. Participation I give Amanda Cremonini, full permission to hypnotise me and to use Rapid Transformational Therapy® knowing that by participating fully in the process and by listening to my personalised recording for 21 days I play an important role in my overall success. Guarantee I understand that although Rapid Transformational Therapy® has an incredibly high success rate, Amanda Cremonini cannot and does not guarantee results since my own personal success depends on many factors that Amanda Cremonini has no control over, including my willingness and desire to affect the changes inside of myself. Audio Recording(s) I give Amanda Cremonini 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) Amanda Cremonini retains full copyright over any forms of media that may be produced and distributed to me. Deepening Process I hereby grant permission to Amanda Cremonini to respectfully lift my arm, touch my shoulder, or rock my head during my Rapid Transformational session(s) in order to help facilitate the deepening process. Confidentiality By submitting this form, I consent that Amanda Cremonini may release information to a specific individual or agency if it has been determined that a vulnerable person (child or elder) is at risk; if I, as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested. I also understand that, at any time, Amanda Cremonini may discuss aspects of my case with other colleagues keeping my full name and identity completely confidential always unless I have given permission otherwise.
This is to inform you what data I am collecting from you and what I intend to do with it.
What data do I keep and why do I need it?
Name and age – this is basic information that helps me get to know you.
Address, email address, phone number – I use this as a way of contacting you regarding your sessions. I will mainly use the method you first contacted me on but if I cannot reach you, I will try a different method.
Next of kin/medical professional’s details – If I was worried that you were at risk then I may need to contact your next of kin or medical professional, if I can. I will let you know when/if I am going to do this.
Session notes – I keep brief notes of our session(s), [add in a description of how these are kept]. Will I share your data and if I do, who will I share it with and for what purpose?
It is very unlikely that I will share your data. I will not sell it on or use it for unethical reasons. I may have to share it if my notes are subpoenaed by court, if you or anyone you tell me about is at harm or risk of harm I may have to pass this information on. I may also discuss your case during supervision but I only use your first name.
How will I store your data?
Example text: It is mainly stored as hard copy in a locked filing cabinet. Immediately after the work is finished, I transfer the data with your initials to my password protected computer. Your phone number(s) may be kept in my business mobile phone with your first name and last initial. Only I will access your information.
How long will I store your data for and how will I dispose of it?
I will keep your details and session notes for the time required by my insurer (currently 7).
After this time I will destroy any document with your personal information and delete your phone number out of my mobile phone.
Do you consent to me using your data in this way? (Required)