Intake Form | Harmonic Perfection

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RTT® Intake Form

WELCOME TO HARMONIC PERFECTION HEALING THERAPIES

Please take your time filling out this form. The answers you provide here play a major role in the overall successful outcome of your session!

𝐖𝐡𝐚𝐭 𝐢𝐬 𝐑𝐓𝐓®?
RTT® stands for Rapid Transformational Therapy,®A healing method developed by an award-winning therapist, Marisa Peer.
RTT® optimizes key elements of Hypnotherpy with Cognitive Behavioral Therapy, Psychotherapy, Psychology, and Neurolinguistic Programming (NLP), known to produce powerful and lasting healing and transformation. RTT® is endorsed by the National and International Council of Psychotherapists, the American Board of Hypnotherapy, the International Association of Complementary Therapists, plus the International Institute of Complementary Therapies.

Legal Name:

Your preferred name?

Email

Phone

Date of Birth

Time of Birth

Place of Birth-City, State, Province, Country

Gender Preference:

Female

Male

Other

Prefer Not to Say

Current Relationship Status;

Please detail your current issues and concerns. Take as much space and share as much detail as possible:

Please describe any treatments and therapies you are currently undergoing or have received for this issue in the past:

Please detail any triggers, thoughts, and feelings you are aware of connected to this issue:

Please close your eyes and imagine what would be different in your life without this problem? How would you act and think differently? What kind of activities would you be doing, creating and co-creating?

on a scale of 1-10, how committed are you to doing whatever it takes to be free from this issue?

Imagine your life a year out without this problem, You are doing what you love, living your most fulfilling life ever, Please describe how your day looks and feels from first thing waking up to last thing before bed?

What else would be a most amazing and welcome outcome of this session for you?

Were you an only child? Please list your siblings in order:

Please share a little about your childhood relationship with parents and extended family?

Anything else about your childhood you would like to share? Relatives, illnesses, significant events?

Please check all that you experienced during childhood:

Acceptance of who you are?

Freedom to express yourself?

Alot of praise?

Kindness, understanding and love?

Trauma

Inability to express yourself

Constant criticism

None of the above

Other

If you answered "Other" above, please describe:

Please check all that apply:

Addictions

Drinking

Smoking

Gambling

Drugs

None

Please check all that apply:

Anxiety

Stress

Burnout

Fears

Phobias

Panic Attacks

Guilt

Shame

Inability to Relax

None

Please check all that apply:

Eating DIsorders

Food/Diet

Weight Issues

Anorexia

Bulimia

Exercise Addiction

None

Other

If you answerd "Other" above, Please provide details here:

Please check all that apply:

Depression

Confidence

Self Esteem

Acheiving Goals

Procrastination

Performance Anxiety

None

Please check all that apply

Career Issues

Interview Skills

Nerves

Public Speaking

Concentration

Exams

Memory Skills

Driving Skills

None

Please check all that apply:

Sexual Problems

Impotence

Frigidity

IVF

Conception

Pregnancy/Birth

None

Do you suffer from any of th following?

Pain Control

Hearing

Sight/Vision

Mobility

Skin Problems

Hair Growth

None

Check all that apply:

Relationships

Intimacy

Childhood Problems

Sleep Rroblems

None

Other

If you checked 'Other" above, Please explain more here:

If any of your issues are not listed above, please describe any symptoms, triggers and habits here:

Legal Waivers

I agree to the terms & conditions

Your Signature

Scope of Practice

I agree to the terms & conditions

Audio Recordings:

I agree to allow Deirdre A. Farrow to make an audio recording that may include my voice:

Commitment and Participation:

I agree to listen to my transformational audio recording for the full 21 days

I agree to being hypnotized by Deirdre A Farrow using Rapid Transformational Therapy

I am 100% committed to my own healing and agree to participate fully in the process

Deepening Processes

I agree

Guarantee

I agree

Confidentiality

I agree

Signatures

Your Signature

Cancellation and Refund Policy

I understand there will be no refund for missed sessions

I understand that I must cancel or reschedule a session within 48 hrs in order to receive a refund or I will forfeit my session.

Your Signature

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