Intake & Consultation form
Rapid Transformational Therapy by Dr Lahvenya
Name
First Name
Last Name
Preferred name
Date of birth & Age
Marital / Relationship status
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Health
Medical history / concerns
Doctor's name & address
Date of last check up ?
Medications & drug history
FROM THE LIST BELOW CIRCLE/TICK YOUR AREAS OF CONCERN
Addiction
Alcohol
Smoking
Gambling
Compulsive behaviour
Anxiety
Stress
Fears
Phobias
Panic attacks
Guilt
Relaxation
Eating problems
Food & diet
Weight issues
Anorexia
Bulimia
Exercise
Depression
Sleeping disorders
Confidence
Self esteem
Motivation
Procrastination
Achieving goals
Career issues
Nerves
Interview skills
Public speaking
Concentrations
Exams
Memory
Driving skills
Sexual problems
Fertility
Sexual problems
IVF
Conception
Pregnancy
Birth
Pain control
Vision/ sight
Hearing
Mobility
Skin problems
Hair growth
Relationships
Childhood problems
Sleep problems
What is SINGLE the most important issue that would like to address with in this session ?
Describe your childhood in general, anything relevant. ie relationship with parents, siblings & family dynamics.
If I had a magic wand, what would be the one vital thing you would love to solve in one session?
Life Without the Problem - What would your life look like without the issue (use strong, powerful, descriptive words) Be specific what would you love to feel, hear, see. How would your day be ?
In a scale 1 - 10 what is the level of your commitment to make lasting change in your life (main issue).
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