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Transforming with Jasmine

RTC® INTAKE AND CONSULTATION FORM

Thank you so much for deciding to go ahead with my coaching program.

I am delighted to be working with you to help you achieve your transformational goals.

To find out more about you and to help clarify what you would like to work on during our time together, please complete this form with some of your personal information. The information you provide will tell me a little about you, your lifestyle, what you want to achieve, and what is holding you back. It will also help me to tailor the coaching program to meet your needs and desired outcomes.

Please answer the questions honestly and to the best of your ability, and note that all the information you provide is completely confidential.

PERSONAL DETAILS

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, positive habits and behaviors to support health

tick the relevant box below

Thanks for submitting!

DISCLAIMER AND DECLARATION

Scope of Coaching

Rapid Transformational Coaching® (RTC®) integrates the effectiveness of Rapid Transformational Therapy® (RTT®), which is a unique, powerful and comprehensive, solution-based approach pioneered by Marisa Peer, one of the world’s most respected therapists. The information, techniques and methods provided by me, 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.

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. You hereby consent that Yasmina Nagnoug Mejai may release information to a relevant individual or agency if it has been determined that a child or adult is at risk of abuse 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.

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