Transform Deeply through Rapid Transformational Therapy - Client Intake Form

Today's Date

Your Name *

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Your Gender - Select Male or Female *

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Your Doctor’s Name

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1. Are you currently receiving any treatment from a Doctor or other Practitioner? - Select Yes or No *

If yes, please give brief details

2. Are you currently taking any medication? - Select Yes or No *

If yes, please give brief details

3. Please give a brief background of your current concern *

4. What do you wish to receive from your session? *

5. What do you still think is in the way of your wish? *

6. What does it look like and feel like if you have fulfilled this wish? Describe what your life would look and feel like. *

7. From the list BELOW please select the areas that concern you *

8. On a Scale of 1 – 10 how committed are you to your personal change? *

DISCLAIMER

People with Epilepsy or any person diagnosed as having a psychotic illness should not enter hypnosis. Katelijn Schutte accepts no responsibility whatsoever. Under no circumstances including but not limited to negligence shall Katelijn Schutte be liable for any special or consequential damages in any way whatsoever now or in the future that result from the use of or the inability to use hypnosis, advanced hypnotic techniques, hypnotherapy or any other therapies. The information, techniques, methods and recommendations by Katelijn Schutte are not intended to substitute for the diagnosis and a care of a qualified doctor nor to encourage the treatment of illness by persons not recognisably qualified. If you use hypnosis and are under medical care for any condition, do not make any adjustments to any prescribed medication without the approval of your doctor. If in any doubt, you should seek medical advice.

Katelijn Schutte has taken due care and attention with the information provided at this therapy session and information is given in good faith. The information given is not intended to constitute medical advice. Always consult your GP before changing medications and evaluating treatment alternatives.

Katelijn Schutte does not accept responsibility for any loss, damage or expense resulting from the use of information provided. You agree to indemnify and hold us harmless by signing and agreeing to these conditions.

Katelijn Schutte carries full professional indemnity and public liability insurance with IICT.

DECLARATION

I declare: *

The information I have given here is to the best of my knowledge, full and correct. I undertake therapy on the understanding that it is a collaborative process, and that progress depends in part upon my own motivation and participation.
I accept that all appointments not cancelled with 24 hours will be charged in full.