Intake Form

Personal Details

Health

From the list below please choose your areas of concern:

Please answer the following questions, giving as much detail as possible:

Disclaimer

Liability

I, (The Client) , hereby release Joanne LytheRao from any liability or claims that could be made against her concerning my mental and/or physical well-being during the work that has been outlined and agreed upon (now and in the future) by filling out this form.

Scope of Practice

I understand that although Rapid Transformational Therapy has an incredibly high success rate, Joanne LytheRao cannot and does not guarantee results since my own personal success depends on many factors that Joanne LytheRao has no control over, including my willingness and desire to affect the changes inside of myself.

Participation

I give Joanne LytheRao full permission to hypnotize me and to use Rapid Transformational Therapy knowing that by participating fully in the process and by listening to my personalised recording for 21 days I play an important role in my overall success.

Guarantee

I understand that although Rapid Transformational Therapy has an incredibly high success rate, Joanne LytheRao cannot guarantee results since my own personal success depends on many factors that Joanne LytheRao has no control over, including my willingness and desire to affect the changes inside of myself.

Audio Recording(s)

I give Joanne LytheRao full permission to make audio recordings that may include my voice. I understand that if a recording (or recordings) are made during or after my session(s) Joanne LytheRao retains full copyright over any forms of media that may be produced and distributed to me.

Deepening Process

I hereby grant permission to Joanne LytheRao to respectfully lift my arm, touch my shoulder, or rock my head during my Rapid Transformational session(s) in order to help facilitate the deepening process.

Confidentiality

By agreeing to the terms in this disclaimer, I consent that Joanne LytheRao may release information to a specific individual or agency if it has been determined that a child or elder is at risk of or is currently being abused; if I, as a client, am in imminent danger to myself or others; or if a subpoena of records has been requested.
I also understand that, at any time, Joanne LytheRao may discuss aspects of my case with other colleagues keeping my full name strictly confidential. My identity will be kept completely confidential at all times, unless I have given permission otherwise.

Data Protection

As a member of the International Association of Counsellors and Therapists, I abide by their code of ethics and data protection guidelines.

Your written session notes are stored in a locked filing cabinet. The data from your intake form is stored on my password protected computer.

Your phone number may be kept in my mobile phone with your first name and last initial. Only I will access your information.

I will keep our session notes for 2 years after our work finishes.

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