Please complete the Client Intake Form Name(Required) First Last Preferred name(Required) First DOB(Required) DD slash MM slash YYYY Current Age(Required) Postal Address(Required) Street Address Address Line 2 Suburb State Postcode Contact Phone No(Required)Email Address(Required) Emergency Contact: Name & Telephone(Required) Relationship Status(Required) Current Occupation(Required) Health & Medical HistoryAny past or present health and medical concerns. Please provide details.(Required) Any history of seizures or epilepsy?(Required) Yes No Any history of psychosis or psychotic episodes?(Required) Yes No What are your main areas of concern?Tick from any and all of the areas of concern(Required) Addictions of any kind Drinking Smoking Drug abuse 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 None of these apply Out of the areas of concern, what do you want to focus on in your first session?(Required) On a scale of 1-10 with 10 being unbearable, how much does this issue impact your life?(Required)Please enter a number from 1 to 10.What have you already tried to overcome this?(Required) What results, if any, did you achieve from this? Symptoms, Triggers, HabitsPlease outline the symptoms (what you experience in your body or mind), the triggers (what situations/people/events set this off) and habits (the things you do/don't do when this issue is activated)(Required)ChildhoodPlease give an outline of your childhood including family structure parents/siblings and any major or minor events of significance that come to mind.(Required)What you want from your sessionIf I could wave a magic wand, what do you most want out of your session?(Required)Life without the problemLet's create your transformation. Imagine life without the problem and describe in some detail what you are doing, how you are feeling, and who you are being? Use as much description as possible as your words will form an important part of your session and transformation.(Required)On a scale of 1-10, with 10 being "highly committed" rate your level of commitment to this process.(Required)Please enter a number from 1 to 10.Terms Of AgreementRapid 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. DisclaimerLiability 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.I have read and agree to the Terms Of Agreement and Disclaimer(Required) I agree Signature(Required)Today's date(Required) DD slash MM slash YYYY If the applicant is under 18, include name of Parent/Guardian Signature Of Parent/GuardianToday's date DD slash MM slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
