Client Symptoms Form Before RTT KIKI YPSILANTI Certified RTT Hypnotherapist (Rank out of 10. 1=Low, 10=High) Date 1 = PoorExcellent = 10 Connection to Others 1 2 3 4 5 6 7 8 9 10 Don't Know Purpose in Life 1 2 3 4 5 6 7 8 9 10 Don't Know Looping Thoughts 1 2 3 4 5 6 7 8 9 10 Don't Know Panic Attacks 1 2 3 4 5 6 7 8 9 10 Don't Know Anxiety 1 2 3 4 5 6 7 8 9 10 Don't Know Depression 1 2 3 4 5 6 7 8 9 10 Don't Know Suicidal Thoughts 1 2 3 4 5 6 7 8 9 10 Don't Know Sleep 1 2 3 4 5 6 7 8 9 10 Don't Know Feeling of Hopelessness 1 2 3 4 5 6 7 8 9 10 Don't Know Anger 1 2 3 4 5 6 7 8 9 10 Don't Know Self-Loathing 1 2 3 4 5 6 7 8 9 10 Don't Know Energy 1 2 3 4 5 6 7 8 9 10 Don't Know Moments of Joy 1 2 3 4 5 6 7 8 9 10 Don't Know Crying Spells 1 2 3 4 5 6 7 8 9 10 Don't Know Laughter and Happiness 1 2 3 4 5 6 7 8 9 10 Don't Know Self Love 1 2 3 4 5 6 7 8 9 10 Don't Know Hope for the Future 1 2 3 4 5 6 7 8 9 10 Don't Know Ability to Stay Calm 1 2 3 4 5 6 7 8 9 10 Don't Know Ability to be kind to myself when I need it most 1 2 3 4 5 6 7 8 9 10 Don't Know General Wellbeing 1 2 3 4 5 6 7 8 9 10 Don't Know Memory – Short Term 1 2 3 4 5 6 7 8 9 10 Don't Know I Am Living My Purpose 1 2 3 4 5 6 7 8 9 10 Don't Know I Deserve Happiness 1 2 3 4 5 6 7 8 9 10 Don't Know What I Want Is Available To Me 1 2 3 4 5 6 7 8 9 10 Don't Know Send Date Connections to Others 1 2 3 4 5 6 7 8 9 10 Don't Know Purpose in Life Looping Thoughts Panic Attacks Anxiety Depression Suicidal Thoughts Sleep Feeling of Hopelessness Anger Self-Loathing Energy Moments of Joy Crying Spells Laughter and Happiness Self Love Hope for the Future Ability to Stay Calm Ability to be kind to myself when I need it most General Wellbeing Memory – Short Term I Am Living My Purpose I Deserve Happiness What I Want Is Available To Me Send