Nicole White Wellness
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Online RTT Intake Form
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Name
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First
Last
Date of Birth
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Age
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Address
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City
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Email
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Marital Status
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Phone Number
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Occupation
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Health Information
Date of Last Check Up
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Known Health Conditions
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Have you had surgery? If so, discribe:
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Are you on any Medications? If so, list them and what are they for
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Do you take supplements? If so, list them here:
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Family History
List current family members that are in your life and the condition of your relationship.
Mother
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Father
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Siblings
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Siblings continued...
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Spouse
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Pets
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Children
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Children continued...
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Briefly describe your childhood
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If any, list issues from your childhood that still affect you.
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Session Details
Please select from the list below areas that concern you:
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Addiction
Depression
Relationships
Gambling
Smoking
Taking Exams
Relaxation
Guilt
Drinking
Eating Problems
Stress
Sleep Problems
Drugs
Fears
Self Esteem
Food
Motivation
Sexual Problems
...continued
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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?
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What do you feel is currently getting in the way of having your desired outcome?
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How long has this been an issue?
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How does this issue affect you/ your work/ family/ hobby/ leisure life?
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What have you done to try to solve this issue in the past? Has it worked? if so, what worked and what didn't?
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How does this issue make you feel about yourself?
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Which of the following seems to be a reoccurring thought?
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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)
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Having this issue resolved will give you what? How will it affect your life?
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Is there anything else you would like me to know?
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Thank you so much for taking the time to provide this information. I'm looking forward to giving you a transformative sessions!
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Believe it will work, and it will!
Home
Results
Work with Me
LymePlexPlus
Anxiety
Eliminate Junk Food
RTT