RTT Client Intake and Consent Form

"Your journey of transformation begins here."

Please take your time answering the following questions openly and honestly.
There are no right or wrong answers — your responses simply help me understand your story and how I can best support you in achieving your desired breakthrough.

Full Name *

Preferred Name *

Email *

Mobile / Whatsapp Number *

Address *

Street Address

City

State

Country

Postal Code

Date of birth *

Relationship Status *

Occupation

Emergency Contact Name

Emergency Contact Number

Doctor's Name and Address

Date of Last Check-up

Medications Being Taken

Health Problems (Past & Current)

I make good decisions and life choices *

Least LikelyMost Likely

My life has meaning and purpose *

Least LikelyMost Likely

I recognize my limiting beliefs and take action *

Least LikelyMost Likely

I am comfortable with who I am *

Least LikelyMost Likely

I am deserving of a loving relationship *

Least LikelyMost Likely

I am true to myself *

Least LikelyMost Likely

I accept that I am lovable *

Least LikelyMost Likely

What would you like to work on or resolve in your upcoming session? *

e.g., stress, confidence, health habits, self-worth, emotional healing, physical issue, career block, etc.

How does this concern currently affect your daily life? *

Please describe how it shows up physically, mentally, emotionally, socially, or spiritually? (e.g. symptoms, habits, patterns, triggers, or situations where it's most noticeable)

Thinking back to your early years, how was your childhood like in relation to this concern? *

Include anything about your family dynamics, school experiences, beliefs you may have developed or recurring emotions

Describe the change or result you wish to experience in your thoughts, emotions, relationships, health, career or overall life? *

Imagine your life completely free from this issue — it’s gone and out of your system for good. What would life look and feel like for you? *

How would you be thinking, feeling, behaving, and showing up each day? What new experiences, opportunities, or relationships would open up for you? How would the people around you notice or benefit from this change?

Why is now the right time for you to make this change? *

What does healing or resolving this mean to you personally at this stage of your life?

Consent

Please read carefully, tick to confirm, and sign below. *

I confirm that I have provided accurate and complete information to the best of my knowledge.

I understand that Rapid Transformational Therapy (RTT® ) is a therapeutic approach and not a substitute for medical treatment, diagnosis, or advice.

I acknowledge that RTT® Practitioners do not work with clients who experience or have psychosis, epilepsy, auditory/visual hallucinations, dissociative disorders, personality disorders, schizoaffective disorder or schizophrenia. I confirm that none of these conditions apply to me.

I understand that results cannot be guaranteed, as outcomes vary between individuals. I take full responsibility of my own wellbeing during and after the session(s).

I consent to participate in RTT® sessions and agree to the terms outlined in the Privacy Policy and Terms and Conditions provided to me.

I have supplied precise emergency contact details in case they are required.

By submitting this form and entering my signature below, I confirm that all information provided is true, complete and accurate to the best of my knowledge. I understand that providing false or incomplete information may affect the effectiveness of my session(s). I also acknowledge my data will be stored securely and used solely for the purposes of my sessions with Valerie Dela Cruz, Myndval Catalyst Ltd.

I acknowledge that I have read, understood, and agree to the Terms & Conditions, Privacy Policy, and Disclaimer provided below.

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Date Signed *

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