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Rapid Transformational Therapy and Clarity Coaching with Susan Intake Form

Take your time and answer these questions with honesty and as much detail as possible. It's all about understanding your current beliefs and mindset because that's where our journey starts. I want your coaching sessions to be totally personalized to you, your reasons, and your unique beliefs. So, be as open as you can, and let's work together to help you reach your goals.

First Name^*

Last Name^*

Preferred name

Email^*

Phone Number

Address

Address Line 1

Address Line 2

City

State or Region

Country

Zip

Age

Birth Date

Occupation

Relationship^*

Emergency contact details:

Emergency contact details: (Include the name, relationship and contact details of your next of kin or who to contact in the case of an emergency)

How did you hear about me? Who referred you?^*

YOUR DESIRED OUTCOMES

Please highlight what you really want and what is holding you back from achieving your full potential in your personal and professional life.

What is the main area of your life that you want to focus on? (tick the relevant box below)^*

Self-development: self-confidence, self-esteem, self-worth, motivation, life purpose, relationships, life balance and self-care
Professional Success: career progression, business success, imposter syndrome, visibility, money mindset, speaking and presenting
Health and Well-being: stress management, anxiety, depression, positive habits and behaviors to support health

What is it that you really want to achieve as a result of the RTC® Coaching Program?^*

What would achieving this aspirational goal do for you?^*

What would it make you think, feel and believe about yourself?^*

How would it make your life different from how it is now?^*

What would be your biggest regret in life if you did not achieve it?^*

What is holding you back and blocking you from making that happen now?^*

What will happen if you stay as you are and do nothing?^*

What have you done so far to work on this?^*

What support would you need to help you take action?^*

On a scale of 1-10, how committed are you to achieving this?^*

WHERE ARE YOU NOW IN THE PAIN OR PLEASURE ZONE?

Complete this self-assessment based on how positive or negative you feel about yourself in these main areas of your life.

Your self-belief^*

Your self-confidence^*

Your inner critic^*

Your purpose and meaning^*

Your coping skills and resilience^*

Your limiting beliefs^*

Your career^*

Your money and wealth^*

Your relationships^*

Your health and well-being^*

Your work/life balance^*

Helping others^*

RAPID TRANSFORMATIONAL THERAPY

Please complete this section to provide some background information in the event you decide to have a Rapid Transformational Therapy® session during the RTC® Coaching Program.

What is the main issue holding you back from achieving your goals that you would like to overcome?^*

Does it show up as any physical or emotional symptoms in you? If yes, what are they?^*

Does the issue result in any specific behaviors or habits? If yes, what are they?^*

Are there any specific triggers or things that makes this issue more challenging at times? If yes, what are they?^*

How would you describe your childhood and experience of growing up?^*

Were there any specific experiences or events that you are aware of that affected you as a child? For example, divorce, bullying, accidents, illnesses, etc.^*

If I could wave a magic wand and achieve ONE thing for you in the session, what would that be? (What do you want? What do you want to transform in this session? Start off by saying, “ I want to .......”)^*

What would your life be like without this issue holding you back? (What would you think, feel and believe about yourself? How would you be? What would you be doing? Think and feel what it would be like for you to really achieve that. Imagine and visualize yourself without this issue and write a few sentences - your transformation statement!)^*

A LITTLE MORE ABOUT YOU

Just a little bit more background

What achievements are you really proud of?^*

What skills and talents do you possess?^*

What do you do that makes you really happy and brings you joy?^*

What hobbies, activities or sports do you do?^*

What were you good at or enjoyed doing as a child?^*

What are your biggest fears?^*

HEALTH INFORMATION

Doctor’s name and address

Are you currently receiving any treatment from a doctor or other practitioner?^*

If yes, please give brief details^*

Medications being taken^*

Health problems (past and current)^*

DISCLAIMER AND DECLARATION

Terms & Conditions^*

Terms of Service
This is to inform you the terms of service I will provide and what is required of you.

CLIENT TERMS AND CONDITIONS

Please read these terms and conditions which apply to the provision of my professional services. By making an appointment, you are agreeing to the following terms and conditions. If you are unable or unwilling to agree to these terms and conditions, then you should not book an appointment or continue with your course of therapy.

FREE INITIAL CONSULTATION

You may be offered a free 20 minute online initial consultation. No therapy will be provided during the consultation.

The purpose of this initial consultation is to get to know each other. During these calls, estimates of the number of sessions required to deal with your presenting issue are given on the basis of the information presented at that time. Estimates are only rough guidelines and are subject to change.

BOOKING & PAYMENT

In-person sessions: A non-refundable deposit of $100.00 is payable at the time of booking your first in-person session. The balance of the fee is due at least 48 hours prior to the first session. No refunds will be issued for cancellations within 48 hours of the session appointment.

Online sessions: No deposit is required for online sessions, however payment for online sessions must be made at least 24 hours before the scheduled session start time. Where payment is not received 24 hours before your session, the session will be cancelled and may be offered to someone else. It is your responsibility to pay the session fees before each scheduled session in order to confirm the appointment booking.

CANCELLATION, RESCHEDULING & REFUNDS

 

Cancellation & rescheduling

If you need to cancel or re-schedule a session, please provide as much notice as possible. Notification must be made via email or phone call at least 48 hours prior to an in-person session or 24 hours for an online session.

Refunds

No refunds will be issued for cancellations within 48 hours of in-person sessions or 24 hours of online sessions.

Session fees are for my time and professional expertise and are not a guarantee of a successful outcome. Therefore, no refunds will be given for any sessions where you have attended and paid for the session.

Where a discount package or therapy program has been booked and paid for in advance, if you choose to discontinue your therapy process before attending all the sessions, a pro rata refund will be issued after deduction of the full standard session fee for any sessions you have attended.

Session Fees

All professional fees will be disclosed to you prior to booking. My professional fees are subject to review and may increase from time to time. You will always receive confirmation of the professional fees before booking.

Payment Methods

Payment may be made online via credit/debit card or e-transfer. Payment for in-person sessions can also be made via credit/debit card at the end of your session. Cash and cheques will not be accepted without prior agreement.

CONTACT BETWEEN SESSIONS

Any contact between sessions will be by telephone, email or letter during office hours only 10am to 4pm. Any messages received outside of these hours will be dealt with during office hours only.

MEDICAL OR PSYCHOLOGICAL CONDITIONS

I may ask questions about your medical history to establish any contra-indications to treatment. This will also help to assess whether your health is affecting (or being affected by) the therapeutic goals you wish to achieve. Please update me of any medical changes during your course of therapy, or if you are returning to therapy after a period of absence.

If you are receiving care or treatment from any medical, healthcare or therapy practitioner, e.g. GP, Psychologist, Psychiatrist or Counsellor, you may be asked to seek their permission before any therapy sessions can commence.

Please note that I will be unable to offer my professional services if you suffer from epilepsy or any form of psychosis.

AGE RESTRICTIONS

You must be at least 18 years old to participate in online sessions. Clients under the age of 18 years old must be accompanied by a parent or guardian and will be seen in-person.

ATTENDING YOUR SESSIONS

Please ensure that you are available at your session start time. If you are running late, please let me know as soon as possible. I will do my best to make a full session available, however, as the ability to do this will depend on bookings after your session, this cannot be guaranteed.

HYPNOTHERAPY RECORDINGS

Hypnotherapy recordings should not be listened to whilst driving, operating machinery or undertaking any other activity where concentration is required. Any recording provided is for your personal use only and must not be shared, lent, copied or sold under any circumstances.

OUTCOME OF SESSIONS

The agreement to work on the issues presented by you in no way implies or guarantees the resolution of your presenting issue(s). No outcome can or will be guaranteed. However, I will always endeavour to use my best efforts and skills to work towards your goals and intended outcomes.

STANDARDS OF BEHAVIOUR

During the course of any therapy sessions, I will treat you with respect and not abuse the trust you place in me. I will use best practice at all times in our mutual interest. In return, you undertake not to harm yourself, or any other person, including me, or any property belonging to either me or any other person.

You agree not to attend sessions under the influence of alcohol or recreational drugs, except those medications which have been prescribed by your doctor. If you do attend any sessions under the influence of alcohol or recreational drugs, or demonstrate violent or abusive behaviour, I will cancel the session and may refuse to see you for any further sessions without refunding any payment already made.

CONFIDENTIALITY

All contact, including sessions, telephone conversations and emails, will be conducted in confidence and may be recorded. Prior to any recording, your agreement will be sought. All recordings, conversations and notes will remain confidential, except in the following circumstances:

Where you give permission for confidentiality to be broken
Where I am compelled by a court of law
Where the information is of a nature that confidentiality cannot be maintained, for example:
The possibility of harm to yourself or others exists
In cases of fraud or crime
When minors (under 18 years old) are involved
Where a referring GP or other healthcare professional requires a report. A copy of the report will be available on
 

LIABILITY & INDEMNITY

Under no circumstances will Susan Lilley be liable for any damages, including without limitation, direct, indirect, incidental, special, punitive, consequential, or other damages (including without limitation lost profits, lost revenues, or similar economic loss), whether in contract, tort, or otherwise, arising out of the advice or information provided to you during professional services provided by Susan Lilley. In addition, you agree to defend, indemnify, and hold Susan Lilley harmless from and against any and all claims, losses, liabilities, damages and expenses (including legal fees) arising out of your participation in the professional services.

GOVERNING LAW

These terms and conditions and any other matters arising out of or in relation to these terms, shall be governed by and construed in accordance with the laws of Ontario, Canada. You agree to submit to the exclusive jurisdiction of the English courts to settle any dispute which may arise out of or in connection with these terms and conditions.

TERMS AND CONDITIONS UPDATES

These terms and conditions are subject to revisions without notice. Please familiarise yourself with any amendments if you have re-started therapy with me after a long period of absence.

DATA PROTECTION

For my services, your personal data is collected, processed, used and stored in accordance with the following Privacy Policy. By booking an appointment, you signify your acceptance of this Privacy Policy. If you do not agree to this policy, please do not book an appointment. The terms of this Privacy Policy may change from time to time without prior notice to you, so please check my website periodically for any changes.

CONCERNS & COMPLAINTS

If you have a concern or complaint regarding your therapy, please discuss this with myself in the first instance and I will endeavour to resolve the issue.

STATEMENTS OF UNDERSTANDING

By signing the Client Agreement, you agree to abide by the terms and conditions of the Client Agreement. You also agree with the statements below:

I confirm that I have been advised by Susan Lilley of the scope of the therapies that she provides and give my full consent to receiving therapy sessions from Susan Lilley

I understand that results may vary from person to person and the agreement by Susan Lilley to work on the issues or problems presented by me, using whatever therapies are appropriate to my situation, in no way implies or guarantees the resolution of any presenting problems or issues.

I understand that hypnotherapy or any other therapy or information provided by Susan Lilley either in person or via telephone, email or internet, is not a replacement or substitute for medical, psychological or psychiatric treatment. If I have any doubts or concerns about my health, I will seek advice from an appropriate qualified healthcare professional.

I declare that, if advised by Susan Lilley prior to or following any therapy sessions, to seek medical approval, I will consult with my GP, hospital consultant and/or other healthcare professional and gain the appropriate written approval for Susan Lilley prior to the next therapy session.

I have been advised that I am free to terminate any or all sessions at any time.

I understand that my level of motivation is vital in the therapy process and I agree to participate to the best of my ability at all times, including making reasonable use of therapeutic suggestions during and between sessions, as well as listening to MP3 recordings and/or carrying out other therapeutic tasks as appropriate.

I have accurately and truthfully answered any questions and provided background information during the initial consultation and /or first therapy session and will continue to do so during any subsequent therapy sessions.

SIGNATURE

It is required that you agree to these terms and conditions before first session. Agreeing to these terms and conditions is your digital signature.

CONFIDENTIALITY

By signing this form, I consent that Susan Lilley may release information to a specific individual or agency if it has been determined that a vulnerable person (child or elder) is at risk; 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, Susan Lilley may discuss aspects of my case with other colleagues keeping my full name and identity completely confidential always unless I have given permission otherwise.

I accept the terms of service.

Scope Of Coaching And Declaration

Scope of Coaching
Rapid Transformational Coaching® integrates the effectiveness of Rapid Transformational Therapy® (RTT®) which is is a unique, powerful and comprehensive solution-based approach pioneered by Marisa Peer, one of the world’s most respected therapists. RTT® combines the most beneficial elements of psychotherapy, hypnotherapy, cognitive behavioral therapy (CBT) and neurolinguistic programming (NLP). The information, techniques and methods provided by the coach are not intended as substitutes for any professional advice such as legal, mental, medical, or other qualified, professional advice. If you are under medical care for ANY condition, do NOT make adjustments to ANY prescribed medication without the approval of your doctor. If in any doubt, you should seek your doctor’s advice.

Working Together Agreement
The Client and Coach have discussed and both agree to the nature of the coaching relationship and the principles, roles, expectations and working arrangements for the duration of the RTC® Coaching Program.

Privacy, Confidentiality and Data Protection
To protect your privacy, all client data is kept strictly confidential and will be stored in accordance with the General Data Protection Regulation (GDPR)/applicable Data Privacy laws. All information is completely confidential always, unless permission is given otherwise. Please read our  Privacy Policy available on our website and note that by agreeing to this section, you consent that the Coach may release information to a relevant individual or agency if it has been determined that a child or adult is at risk of or is currently being abused; or if you as a client are an imminent danger to yourself or others; or if a subpoena of records or any other requirement to share information by law has been requested.

Complaints Policy
We are committed to providing a high quality service but in the unlikely event that you wish to make a complaint, please read the Complaints Policy on our website which sets out a clear procedure for doing so.

Declaration
The information I have given here is, to the best of my knowledge, full and correct. I undertake the RTC® Coaching Program and Rapid Transformational Therapy® on the understanding that it is a collaborative process and that progress and success are dependent upon my motivation and participation.

I agree

I would love to share my experience, and submit a testimonial if requested.^*

Yes, I would love to provide a testimonial.
No

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