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RTT Client Intake Form
All information is Strictly Confidential.
First & Last Name
*
Preferred Name
Gender
*
Preferred Pronouns
*
Age
*
Date of Birth
*
Month
Occupation
Email
*
Address
Emergency Contact Name
*
Emergency Contact Phone
*
Are you currently receiving any treatment from a Doctor or other Practitioner? If yes give brief details?
*
Are you currently taking any medication? If yes please give details?
*
What are you wanting to address & achieve from your RTT session? Please be as specific as possible.
*
Which are your areas of concern.
*
Addictions:
Drinking
Drugs
Smoking
Gambling
Compulsive Behavior
Anxiety
Stress
Fears
Phobias
Panic Attacks
Guilt
Relaxation
Eating Problems
Anorexia
Bulimia
Weight Problems
Exercise
Food/Diet
Depression
Confidence
Self-Esteem
Motivation
Achieving Goals
Procrastination
Career Issue
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
Relationship
Childhood Problems
Sleep Problems
Other
Any other concerns not listed?
History: Is there any illness, distress, or other concern in your history that is relevant to your session or that you think we should know about? Please give details:
*
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