Rapid Transformational Therapy – Intake Form

First Name *

Last Name *

Phone Number *

Email *

Age *

Relationship Status *

What would you most like me to help you with? *

Can you tell me what your symptoms, triggers and habits are for the issue that you would like to work on? *

Are you an only child or do you have siblings? *

Is there anything about your family that you think may be relevant to how you are today? *

What would you like to achieve from our session? *

What will your life be like without this issue? *

What would the best version of you look like? (How would you feel, what would you look like, who would you be?) *

Is there anything else you think I need to know? *

4 + 3 = ?Please prove that you are human by solving the equation *