1. Your Details

First Name *

Last Name *

Preferred Name

Phone *

Email *

Date of birth *

Address

Street Address *

City *

Region *

Country *

Postal Code *

Occupation *

Relationship Status

Emergency Contact Name *

Emergency Contact Phone Number *

Relationship to you *

2. Medical Details

Are you currently under the care of a doctor, psychologist, psychiatrist, or other health professional? *

Yes

No

Doctors name and address *

Are you currently taking any prescribed medication? *

Yes

No

Details of medications *

Have you ever been diagnosed with a mental health diagnosis and/or suffered from epilepsy, psychosis, psychotic episodes, schizophrenia, hallucinations, or a personality disorder? *

Yes

No

Please provide details

Have you experienced suicidal thoughts or self-harm within the past 12 months? *

Yes

No

Please provide details

Hypnosis is not suitable for the above conditions. Please confirm in the box below that you do not have any of these conditions. *

Yes

Have you ever been hypnotised before? *

Yes

No

Maybe

Previous Hypnosis Experience Details

List medical history/allergies/health problems

Do you consent to Michelle Domenghini contacting your doctor or healthcare provider if necessary? *

Yes

No

Description of the issue you want to focus on *

Which of the following areas are currently not where you'd like them to be?
Select any that apply.

Relationships and Personal Life

Relationships

Communication

Boundaries

Childhood influences / early experiences

Other (please specify)

On a scale of 1-10 (1 no impact at all and 10 being "I can't cope") how much impact does this issue have on your life?

On a scale of 1-10 (1 being not committed at all and 10 being fully committed) how committed are you to changing this?

3. Nature of Rapid Transformational Therapy (RTT®)

Michelle Domenghini C.Hyp, RTTP® is a Certified Rapid Transformational Therapy® Practitioner and Certified Hypnotherapist.

She is not a registered medical practitioner, psychologist, psychiatrist, or licensed health provider.

RTT® is a complementary therapeutic approach and does not constitute medical, psychiatric, or psychological treatment.

You acknowledge that:

You will remain aware and in control during hypnosis.
You may choose not to accept any suggestion.
Hypnosis does not override your will.
You should not stop or alter any medication without consulting your doctor.
RTT® is not appropriate for individuals experiencing psychosis or certain serious psychiatric conditions.

I acknowledge that I have read and understood the nature of Rapid Transformational Therapy® as described above. *

Yes

4. Participation & Responsibility

By proceeding, you acknowledge that:

You are voluntarily participating in RTT®.
You accept responsibility for your own decisions, actions, and wellbeing.
Personal change requires engagement and commitment.
You agree to listen to your personalised audio recording for a minimum of 21 consecutive days following your session.

Specific outcomes cannot be guaranteed. Progress depends on individual circumstances, engagement with the process, and the nature of the presenting concern.

I acknowledge that I am voluntarily participating in RTT®, accept responsibility for my own decisions and wellbeing, agree to engage fully in the process including listening to my personalised audio recording as instructed, and understand that specific outcomes cannot be guaranteed. *

Yes

5. In-Person Session Consent

For in-person sessions, light physical contact may be used to assist with relaxation and deepening of trance.

This may include gently lifting your arm or lightly touching your head.

Such contact will always be appropriate and respectful. You may withdraw consent at any time.

I consent to appropriate and respectful light physical contact during in-person sessions, as described above, and understand that I may withdraw this consent at any time. *

Yes

No

6. Confidentiality

All information shared during sessions is treated as confidential.

Confidentiality may be limited where there is a serious and imminent risk of harm to you or another person, suspected abuse of a child or vulnerable person, or where disclosure is required by law.

Michelle Domenghini may discuss aspects of your case for professional supervision purposes. Any such discussion will remain anonymised.

7. Privacy & Data Protection

Your information is collected and held in accordance with the Privacy Act 2020 (New Zealand).

Information collected may include personal contact details, health disclosures, session notes, and communication records.

Information is stored securely using password-protected digital systems and/or locked physical storage where applicable.

Client records are retained for a minimum of seven (7) years from the date of your last session.

You have the right to request access to or correction of your personal information.

8. Fees & Cancellation

Sessions must be cancelled or rescheduled with at least 48 hours’ notice.

Sessions cancelled with less than 48 hours’ notice may be forfeited unless exceptional circumstances apply.

Payment terms are agreed prior to commencement of services.

9. Declaration & Consent

By signing or submitting this form, you confirm that:

The information provided is accurate and complete.
You have read and understood this agreement.
You understand the nature and scope of RTT®.
You consent to participate in Rapid Transformational Therapy®.
You consent to the collection and storage of your information as outlined above.
Where applicable, you consent to light physical contact during in-person sessions.

I confirm that the information provided is accurate and that I consent to participate in Rapid Transformational Therapy® under the terms outlined above. *

Yes

Please type your full name as your digital signature. *

Client Intake Form

3. Nature of Rapid Transformational Therapy (RTT®)

Send Client Intake Form