First Name *

Last Name *

Age *

Phone *

Time Zone You Are Located In?

Email *

Country *

City *

State *

Relationship Status *

Preferred Pronouns (optional)

Gender (male, female, etc.) *

Occupation (student, homemaker, caregiver, nurse, etc.) *

Referred by Internet, Facebook, YouTube, Advertisement, Friend - list friends name

Current overall health condition *

What TOP 3 issue(s) would you most like support with right now? (Examples: anxiety, confidence, past trauma, PTSD, money mindset, health challenges, depression, relationship issues, people pleaser, etc.) *

1st
2nd
3rd

How many months or years have you been experiencing these issues? *

What have you already tried to improve or resolve this issue? (talk therapy, meditation, EDMR, coaching, journaling, self-help, etc.) *

If we could wave a magic wand, what would your ideal outcome look like? Be very descriptive, let your imagination go wild!! I want you to close your eyes & think of your ideal dream life from how you wake up, taking time for yourself ** Paint (write) me a picture of a life without the issues you have chosen to work on.** All this will go into the customized transformational audio you will receive & listen to for at least 21 days and best time to listen to it is at bedtime & fall asleep to it. *

What would success in this area of your life allow you to do, be, or feel? Be open & honest, I will be able to help you more & you will receive more out of the session. *

Are you committed to following through with the process, including listening to your personalized transformational audio daily for at least 21 days? *

Yes

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Do you currently experience or have a history of the following? *

Epilepsy or seizures

Severe mental health conditions (psychosis, schizophrenia, schizoaffective disorder)

Current substance dependency (alcoholism, narcotics, benzodiazepines, opioids, or recreational/illegal drugs)

None of the above

Are you under the care of a physician or therapist for this concern? *

Yes

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Client Acknowledgment, Health Disclosure & Electronic Signature By entering my name and electronically signing this form. Read details below. *

Clear

Client Acknowledgment, Health Disclosure & Electronic Signature By entering my name and electronically signing this form, I acknowledge and agree to the following: Nature and scope of services: Breakthrough Calls, Rapid Transformational Therapy (RTT®), hypnotherapy, coaching, and related resources provided by Fran Smith through Mind Glow Transformations LLC are intended to support personal growth and general wellbeing. These services do not replace medical care, psychotherapy, psychiatric care, or other treatment provided by a licensed healthcare professional. In providing these services, Fran Smith is acting as a transformational coach and RTT® hypnotherapist, rather than as my medical or mental health treatment provider. Medical disclaimer: Information provided through the website, sessions, recordings, or other materials is for educational and general wellness purposes. It is not medical advice, diagnosis, or treatment. I understand that I should consult my physician or qualified mental health professional regarding health concerns and should not delay seeking care, discontinue treatment, or change prescribed medication based on these services. Health disclosure and screening: To the best of my knowledge, I confirm that I do not have epilepsy or a seizure disorder and have never been diagnosed with psychosis, schizophrenia, or schizoaffective disorder. I agree to disclose other medical or psychiatric conditions, medications, and current treatment that may affect my suitability for hypnotherapy. If I cannot confirm these statements, or am uncertain, I will contact Fran Smith before participating in hypnosis or RTT®.

By checking this box, I consent to receive non-marketing text messages from Mind Glow Transformations about Breakthrough Call. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from Mind Glow Transformations at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.