Client Intake Form | Start Your Transformation Today

First name

Last name

Email

Date & Time availability for discovery call and/or session

Please list preferred times & your availability so we can do our best to offer you a convenient time.

Clinic or Online Session

Time Zone if booking Online Session

Please list the town, state & country you'll be in for your online session... to ensure scheduling accuracy

Phone Number

I use whats app for international calls for initial chats so please include country codes.

Current living situation

Occupation

Doctor's name, address & date of last check up

Please list all medications & supplements being taken

Diagnosed Mental Health Conditions

Do you have any diagnosed or suspected mental health conditions (e.g. bipolar disorder, autism, PTSD, anxiety, depression) that you feel it would be helpful for me to be aware of in our work together?

What are you looking to acheive through this process ?

Please give me some detail about what you want to change.

What is the main thing holding you back ?

How much does the above hold you back on a scale of 1-10 ?

( 1 being not at all + 10 Alot )

How committed to change are you on a scale of 1 - 10 ?

1 = Not very

10 = Absolutely Committed

If your issue is a physical illness or problem. Please explain & list your symptoms and any triggers, doctors recommendations/prognosis & any info you feel relevant in as much detail as you can..

How would you like to feel on a day to day basis. Please describe your ideal scenario in terms of how you feel in your mind and body

If you were living the best version of your life, what activities and past times would you be doing that you are not doing or unable to do now?

If you were free from this issue - what would this mean you could go on to do in the future?

Give some examples of the kinds of things you say to yourself on a regular basis

Please give a brief description of your family background

Please add anything you feel is relevant in relation to the selections you've made or issues you struggle with... (even if not listed)

Have you had hypnosis before:

If yes, what for & how helpful was it? If no - are you open minded about it?

How did you hear about Charlotte ? If referred pls let me know by whom...

POST SESSION COMMITMENT

I commit to listening to my recording.

I understand the importance of listening to my personalised recording daily, for at least 3 weeks to ensure optimum results

CANCELLATION TERMS

I agree to the below cancellation terms

For sessions, full payment is payable on booking to confirm the session - non refundable within 30 days. (Please read T's & C's as appointments can be changed in serious circumstances)

For personalised recordings - payment is due on ordering.

Please indicate what service you are interested in, be it individual RTT sessions, coaching, a package ( see pricing page) or a personalised recording?

I have read through and agree to the Terms & Conditions sent to me

https://www.charlotteferrier.com/ts-cs

Multi choice

I understand and agree

I give my consent to working with Charlotte

Date of Birth

Application for Coaching, RTT & Transformational Hypnotherapy with Charlotte Ferrier