RTT Confidential Intake Form

Nicole White Wellness

Rapid Transformational Therapy Intake Form

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All information entered is strictly confidential. Nicole White Wellness & Rapid Tranformational Therapy.

Online RTT Intake Form

* Indicates required field

Name *

First

Last

Date of Birth *

MM/DD/YYYY

Age *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Marital Status *

Phone Number *

Occupation *

Health Information

Date of Last Check Up *

Known Health Conditions *

Have you had surgery? If so, discribe: *

Are you on any Medications? If so, list them and what are they for *

Do you take supplements? If so, list them here: *

Family History

List current family members that are in your life and the condition of your relationship.

Mother *

Father *

Siblings *

Siblings continued... *

Spouse *

Pets *

Children *

Children continued... *

Briefly describe your childhood *

If any, list issues from your childhood that still affect you. *

Session Details

Please select from the list below areas that concern you: *

Addiction Depression Relationships Gambling Smoking Taking Exams Relaxation Guilt Drinking Eating Problems Stress Sleep Problems Drugs Fears Self Esteem Food Motivation Sexual Problems

...continued *

Achieving Goals Memory Self Hypnosis Anxiety Nerves Career Confidence Panic Attacks Weight Problems Childhood Problems Phobias Anorexia Bulimia Public Speaking Compulsive Behavior Fertility Work-a-holic Other

What is your ideal outcome for your session? *

What do you feel is currently getting in the way of having your desired outcome? *

How long has this been an issue? *

How does this issue affect you/ your work/ family/ hobby/ leisure life? *

What have you done to try to solve this issue in the past? Has it worked? if so, what worked and what didn't? *

How does this issue make you feel about yourself? *

Which of the following seems to be a reoccurring thought? *

I am not enough. I can't get what I want. I'm different

So... If I had a magic wand - what is your ideal outcome for the session?

(Please state in a positive way) *

Having this issue resolved will give you what? How will it affect your life? *

Is there anything else you would like me to know? *

Thank you so much for taking the time to provide this information. I'm looking forward to giving you a transformative sessions!

Submit

Believe it will work, and it will!

Home
Results
Work with Me
LymePlexPlus
Anxiety
Eliminate Junk Food
RTT