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Emergency Name and Contact
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Date of last check up
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Medications being taken
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FROM THE LIST BELOW MARK THE AREAS THAT CONCERN YOU
Achieving Goals
Addictions
Anger
Career
Catastrophising
Childhood Problems
Compulsive Behavior
Confidence
Depression
Eating Issues
Emotional Blocks
Exams
Fears (Heights, Driving, Flying, Needles, Dentist, etc.)
Feeling unlovable or unworthy
Finding love
Guilt
Health Issues
Improve Memory, Focus, Concentration
Lack of Connection
Migraines
Money Block/Issues
Motivation
Pain Control
Phobias
Procrastination
Public Speaking
Premenstrual Tension
Premenstrual Dysphoric Disorder
Relationship issues
Rest & Relaxation
Rheumatoid Arthritis
Self-Esteem
Skin Problems
Sleep Problems
Smoking
Sports Performance
Stress
Success Blocks
Trauma: Unresolved, from your past
Wealth Wiring
Weight Control
1) Explain briefly in your own words the issue/s for which you want an RTT session.
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2) What is it that you would like to achieve from this therapy?
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3) What are the triggers to these situations, symptoms related to them if any, and habits that induce them, if any?
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4) Have you ever had suicidal thoughts?
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6) Have you had a history of epilepsy, schizophrenia, psychotic disorder?
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