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My Story
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Work With Me
FAQ’s
What Is RTT
What problems does RTT solve
RTT Associations
Health Providers
Contact Me
BOOK A CALL
GR
EN
Home
My Story
Testimonials
Work With Me
FAQ’s
What Is RTT
What problems does RTT solve
RTT Associations
Health Providers
Contact Me
Menu
Home
My Story
Testimonials
Work With Me
FAQ’s
What Is RTT
What problems does RTT solve
RTT Associations
Health Providers
Contact Me
BOOK A CALL
GR
Home
My Story
Testimonials
Work With Me
FAQ’s
What Is RTT
What problems does RTT solve
RTT Associations
Health Providers
Contact Me
Menu
Home
My Story
Testimonials
Work With Me
FAQ’s
What Is RTT
What problems does RTT solve
RTT Associations
Health Providers
Contact Me
Book Your Appointment
KIKI YPSILANTI
Certified Hypnotherapist, Certified RTT Therapist
First Name
Last Name
Preferred Name
Date of Birth
Address
Previous treatments (specify):
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Date
Relationship Status
Occupation
Email Address
Telephone Number
Emergency Contact Name
Telephone Number
SMOKING
YES
NO
ALLERGIES
YES
NO
PREGNANCY
YES
NO
Doctor’s Name and telephone number
Medications
HEALTH PROBLEMS/Medical Conditions- Mental & Physical (Past & Current)
FROM THE LIST BELOW TICK YOUR AREAS OF CONCERN:
Addictions
Drinking
Smoking
Drugs
Gambling
Compulsive Behaviour
Anxiety
Stress
Fears
Phobias
Panic
Attacks
Guilt
Relaxation
Eating Problems
Food /Diet
Weight Problems
Anorexia
Bulimia
Exercise
Depression
Confidence
Self Esteem
Motivation
Achieving Goals
Procrastination
Career Issues
Interview Skills
Nerves
Public Speaking
Concentration
Exams
Memory
Driving Skills
Sexual Problems
Fertility
IVF
Conception
Pregnancy
Birth
Pain Control
Hearing
Sight/Vision
Mobility
Skin Problems
Hair Growth
Insomnia
Relationships
Childhood Problems
Sleep Problems
Perfectionism
Money blocks
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