RTT® — Intake Form – Deep Work for Men

RTT Full Intake Form

First Name

Last Name

WhatsApp number

Your country

Your timezone

Your age

What’s going on

Be as honest as you can here. The more specific you are, the more useful our discovery call will be.

What is the main thing you want to work on in this session?

How long has this been going on?

How is this affecting your daily life right now?

What have you already tried?

Going deeper

These questions go further. Take your time with them.

When you think about this issue — what emotions come up most?

Is there a repeating pattern you’ve noticed?

What does the voice in your head say about this — at your lowest?

Is there anything from your past — childhood, family, a specific event — that you feel may be connected to this?

Health and safety

This section is important for your safety and mine. Please answer honestly.

Are you currently under the care of a doctor, psychiatrist, or therapist?

Yes

If yes — what are you being treated for, and are they aware you are doing this work?

Are you currently taking any medication — prescribed or otherwise?

Are you currently experiencing suicidal thoughts or self-harm urges?

Yes — passive thoughts only (not acting on them)

Yes — actively

If you selected the third option, please reach out directly before our session. RTT® is not the right starting point and I want to make sure you get the right support.

How would you describe your emotional stability right now?

Stable — I have difficult moments but I’m generally functioning

Somewhat unstable — I’m struggling more than usual

Very unstable — I’m in crisis

Is there anything else about your health or history that feels important for me to know?

What you want

Almost done. These last questions help me prepare specifically for you.

If this session worked — what would be different in your life 3 months from now?

What would it mean to you personally to finally shift this?

How ready are you to do your part — the recording, the actions, the honesty?

10 — Completely committed

7-9 — Very ready

4-6 — Fairly ready

1-3 — Still figuring it out

Practical

A few quick practical questions.

Have you ever experienced hypnotherapy or RTT® before?

Yes

If yes — briefly, what was your experience?

Will you have a private, quiet space for the session with no interruptions?

Yes

I’ll need to arrange this

Do you have headphones and a stable internet connection?

Yes

I need to check this

Consent and agreement

Please read each statement carefully before ticking.

I confirm my answers are honest. I understand this is not medical treatment.

Yes

I understand that RTT® does not replace professional medical or psychiatric care.

Yes

I take responsibility for my own participation — including listening to my recording and completing my 21-day actions.

Yes

I understand that results are not guaranteed and depend significantly on my engagement and honesty.

Yes

I consent to our session being recorded for the purpose of creating my personalised audio recording. This recording will not be shared with anyone.

Yes

I consent to my information being stored securely and used only in the context of our work together.

Yes

I understand that RTT® does not replace professional medical or psychiatric care.

Yes

I confirm I am emotionally stable enough to participate in this work at this time.

Yes