Intake & Consultation Form - Be Heard, Be Brave, Be Free

Personal Details

Surname *

Forename: *

Preferred Name:

Date of Birth *

Relationship Status:

Occupation:

Email Address: *

Phone: *

Emergency Contact Name: *

Emergency Contact Number: *

Client Feedback

How did you feel before the RTT® session?

How do you feel 21 days after the RTT® session & listening to the recording?

DISCLAIMER AND DECLARATION

Scope of Coaching & Therapy *I confirm I have read this and agreeRapid Transformational Coaching® (RTC®) integrates the effectiveness of Rapid Transformational Therapy® (RTT®), which is a unique, powerful and comprehensive, solution-based approach pioneered by Marisa Peer, one of the world’s most respected therapists. The information, techniques and methods provided by the coach/therapist are not intended as substitutes for any professional advice such as legal, mental, medical, or other qualified, professional advice. If you are under medical care for ANY condition, do NOT make adjustments to ANY prescribed medication without the approval of your doctor. If in any doubt, you should seek your doctor’s advice.

Privacy, Confidentiality and Data Protection *I confirm I have read this and agreeTo protect your privacy, all client data is kept strictly confidential and will be stored in accordance with the General Data Protection Regulation (GDPR)/applicable Data Privacy laws. All information is completely confidential always, unless permission is given otherwise. You hereby consent that the Coach/Therapist may release information to a relevant individual or agency if it has been determined that a child or adult is at risk of abuse or is currently being abused; or if you, as a client, are an imminent danger to yourself or others; or if a subpoena of records or any other requirement to share information by law has been requested.

Thank you for taking the time to complete this form and I look forward to working with you soon.