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Rapid Transformation Therapy Parent/Guardian Child Intake Form

Rapid Transformation Therapy Parent/Guardian Child Intake Form

Thank you for confirming you would like me to work with your son/daughter. Please complete the following consent form to enable me to proceed. This form is essential for the safeguarding of your child and insurance purposes. I believe that everyone has the potential to be amazing, wonderful and extraordinary and what I love about working with young people is that I can help them to rapidly overcome the challenges they face in the modern day so that it serves them well for their future. This unique therapy and my expertise in helping children and young people to overcome stress, anxiety, lack of confidence, depression, grief and overwhelm uses mind body connection techniques to bring back a state of balance so that they can be more resourceful, happy, confident, fulfilled and realise their true potential. I am looking forward to working with you and your son/daughter using this incredible approach.
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    Pick a Date
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    Please be advised if you have epilepsy I will need your doctors permission
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    If yes please briefly describe your experience
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    On a scale of 1 - 10 from your perspective as a parent/guardian
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    Not at all
    Highly Effects home life
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    On a scale of 1 - 10, from your perspective as a parent/guardian
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    If you have already answered these questions during our discovery call please add any additional information you feel might be helpful if applicable.
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    Do you notice any triggers? (If you have already answered these questions during our discovery call please add any additional information you feel might be helpful if applicable.
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    If you have already answered these questions during our discovery call please add any additional information you feel might be helpful if applicable.
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    If you have already answered these questions during our discovery call please add any additional information you feel might be helpful if applicable.
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    Terms and Conditions
    It is my policy to provide clients with general information about treatment status. I may
    raise issues that may impact the child or adolescent either inside or outside the home,
    school or sports programme. If it is necessary to refer the child to another professional withmore specialised skills, I will share that information with you and seek your permissionaccordingly.


    Confidentiality and Safeguarding
    The sessions with your child are confidential and I will not share with you what your child
    has disclosed to me without the child’s consent, however under the safeguarding act I will
    be required to report any disclosures if the child is at significant harm by a person or
    themselves. If this occurs while I am working with your child through a referral from the
    school, I will be required to report it to the head of house and safeguarding officer. Should
    this occur during my private practice session I will be required to report it to my local
    authority safeguarding officers, raise a MASH referral or any other appropriate external
    agency. For more information on safeguarding this website contains useful
    information https://www.gov.uk/topic/schools-colleges-childrens-services/safeguardingchildren.


    At the end of the session I will ask the child if there is anything that he or she may want to
    share with you. If your child decides to keep the information confidential and is not
    considered at harm of risk I am bound by the confidentiality agreement, however I will sharewith your child that I will summarise the session for you and with the teachers who referredyour child in order to provide the child with more support from teachers, parent or coaches.


    Please note this is explained within the child’s intake form and I re-address it during the
    start of the session for understanding.


    I highly recommend for you to discuss the terms and conditions with your child together so
    they fully understand.


    I may occasionally find it helpful to consult other professionals about your child and during
    this time i make every effort to avoid revealing the identity of your child. The consultant is
    also legally required to keep all details confidential.


    Caution
    Epileptics or anyone diagnosed as having a psychotic illness are advised to obtain consent
    from their doctor. I accept no responsibility whatsoever. Under no circumstances including
    not limited to negligence shall Claire Linturn be liable for any special or consequential
    damages in any way whatsoever now or in the future that result from the use of or the
    inability to use hypnosis/advanced hypnosis techniques/hypnotherapy or any other
    therapies.


    During RTT or any other methods I provide such as breathing or tapping techniques, clients may experience some emotional releases (abreactions) like crying, yawning, shaking, laughing etc, which is perfectly normal as it’s the body’s way of finally letting go. After the session, clients may also experience more emotions, from feeling lighter and happier to feeling a little bit foggy or tearful.


    Disclaimer
    Claire Linturn has taken due care and attention with the information provided and the
    information is given in good faith. You have the opportunity to call me to discuss any of the
    services I provide.


    I, (The Client or guardian/parent) , hereby release Claire linturn (The therapist) from any
    liability or claims that could be made against (him/her) concerning your childs mental
    and/or physical well-being during the work that has been outlined and agreed upon (now
    and in the future) by filling out this form.


    Participation
    I give Claire Linturn give full permission to use Rapid Transformational Therapy knowing
    that by participating fully in the process and by listening to the personalized recording for
    28 days your child plays an important role in the overall success.


    I understand that Claire Linturn may have to include light touching during the process with
    an in person session which will a light touch on the harm, rocking or tapping of the head to
    assist with deepening technqiues during the method and my child will be advised this may
    happen. Please discuss this with your child so they understand.


    Guarantee
    I understand that although Rapid Transformational Therapy has an incredibly high success
    rate, Claire Linturn cannot and does not guarantee results since your childs own personal
    success depends on many factors that Claire Linturn has no control over, including you and
    yours childs willingness and desire to affect the changes inside of themselves and with your support.


    It is helpful to remember that our relationship is professional and not social. Our
    professional relationship is of utmost importance as we work together towards achieving
    resolution and healing to the child’s life. Both you and the child or adolescent are in
    complete control and may end the relationship at any time, although I do ask that the child or adolescent participates in a termination session. I have been trained to a high standard to cause no psychological harm, however you both also have the right to refuse my techniques or suggestions that you believe might be harmful.


    Contact
    Should you wish to contact with me regarding your child specifically about the RTT session,
    please email me at hello@clairelinturn.com and I will come back to you when I am available during my working hours. Should your query be urgent and your child needs to be seenplease refer to your doctor or local Childs mental health services. Should the issue be school related please refer back to your head of house and they will notify me if necessary to make contact with you when I return to the school.


    If you wish to speak with me in person or over the phone please notify me by email and I
    will advise when I have availability.


    Using Rapid Transformation Therapy generally between 1 – 3 sessions are required for a
    single issue, however some clients may need more depending on the work they do for
    themselves with the method. Please understand this method is highly effective for
    understanding the negative behaviours, habits and physical symptoms. Your child is not
    broken and it is not my responsibility to fix them. It is very important to be highly motivated in wanting to change and I have to meet the child where they are and what is important to them using RTT techniques and listen to the recording for the 28 days for the therapy to have the greatest impact. During the 28 days I will be making contact via email, mobile with your permissions only. It is essential that parents and guardians support the process. I cannot be held responsible for the outcome of the treatment should your son/daughter refuse the techniques or suggestions and you as parents/guardians choose not to support the process.


    The testimonials I receive are the views of my clients. I cannot guarantee you will have
    exactly the same results as them as results will vary from person to person.


    The information, techniques, methods and recommendations by Claire Linturn is not
    intended to substitute for diagnosis and care of a qualified physician/GP. If you use hypnosisand are under medical care for any condition do not make any adjustments to any prescribe medications without the approval of the doctor. If in doubt you will need to seek your GP’s advice.

    Presence during a Zoom session:

    I will not conduct any zoom sessions without the presence on an adult in the house. I highly recommend the privacy of your childs session without you in the room. By consenting to your child working with me over zoom you understand you are required to be in the house during this time.


    *RESULTS ARE NOT GUARANTEED

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    Additional requirements for working via Zoom/Skype

    The same Policy and Privacy Statement applies as previously supplied and can be found on my website www.creativecoachingtherapy.co.uk/contact.

    Your​ ​Zoom/Skype​ ​RTT​ ​Session Your​ ​RTT​ ​session​ ​over​ ​Zoom/Skype​ ​will​ ​last​ ​2 -2.5​ ​hours​ ​which​ ​includes​ ​a personalised​ ​recording​ ​that​ ​you​ ​are​ ​required​ ​to​ ​listen​ ​to​ ​for​ ​28​ ​days​ ​following your​ ​session. ​ ​The​ ​recording​ ​will​ ​reinforce​ ​the​ ​work​ ​we​ ​do​ ​during​ ​your​ ​session. Your​ ​recording​ ​will​ ​be​ ​sent​ ​to​ ​you​ ​by​ ​(email/WhatsApp/Messenger).

    Presence during a Zoom session with under 18's:

    I will not conduct any zoom sessions without the presence on an adult in the house. I highly recommend the privacy of your childs session without you in the room. By consenting to your child working with me over zoom you understand you are required to be in the house during this time.

    By​ ​choosing​ ​to​ ​partake​ ​in​ ​your​ ​RTT​ ​session(s)​ ​you​ ​confirm​ ​that​ ​you​ ​do​ ​not​ ​have epilepsy,​ ​or​ ​any​ ​current​ ​medical​ ​issues​ ​that​ ​would​ ​put​ ​you​ ​at​ ​risk​ ​during​ ​the duration​ ​of​ ​your​ ​session(s).​ ​

    Zoom​ ​sessions​ ​require​ ​a​ ​link​ ​which​ ​I​ ​will​ ​send​ ​to​ ​you​ ​prior​ ​to​ ​your​ ​session​ ​by email. Session​ ​Requirements:

    ● A​ ​comfortable​ ​chair​ ​with​ ​a​ ​back​ ​that​ ​is​ ​low​ ​enough​ ​so​ ​your​ ​feet​ ​touch​ ​the floor. Or you may wish to position your computer so that i can see you while lying on a couch or your bed.

    ● A​ ​decent​ ​pair​ ​of​ ​headphones.

    ● A​ ​webcam​ ​with​ ​a​ ​clear​ ​signal.

    ● A​ ​space​ ​where​ ​you​ ​will​ ​not​ ​be​ ​distracted.

    ● A​ ​strong​ ​internet​ ​connection.

    ● Make​ ​sure​ ​you​ ​face,​ ​eyes,​ ​and​ ​arms​ ​are​ ​clearly​ ​visible.

    *Please​ ​download​ ​and​ ​test​ ​Zoom/Skype​ ​before​ ​your​ ​session.

    What​ ​if​ ​the​ ​internet​ ​connection​ ​drops?

    If​ ​the​ ​internet​ ​connection​ ​drops​ ​at​ ​any​ ​point​ ​throughout​ ​your​ ​session,​ ​you​ ​will naturally​ ​come​ ​back​ ​to​ ​a​ ​normal,​ ​waking​ ​state​ ​of​ ​reality.​ ​At​ ​this​ ​point,​ ​you​ ​can simply​ ​reconnect​ ​and​ ​we​ ​will​ ​resume​ ​your​ ​session. *If​ ​the​ ​internet​ ​connection​ ​drops​ ​during​ ​the​ ​Transformation​ ​phase​ ​of​ ​your​ ​RTT session,​ ​do​ ​not​ ​attempt​ ​to​ ​reconnect.​ ​I​ ​will​ ​be​ ​making​ ​a​ ​recording​ ​for​ ​you.​ ​Once​ ​I have​ ​finished​ ​making​ ​your​ ​recording​ ​I​ ​will​ ​reconnect​ ​with​ ​you​ ​and​ ​ ​wrap​ ​up​ ​the rest​ ​of​ ​the​ ​session.

    Contact Details: 07786004371

    Before​ ​taking​ ​part​ ​in​ ​your​ ​zoom/skype RTT​ ​session(s),​ ​please​ ​ensure:

    1. That​ ​you​ ​do​ ​not​ ​suffer​ ​from​ ​epilepsy.

    2. That​ ​you​ ​will​ ​ ​be​ ​free​ ​from​ ​the​ ​influence​ ​of​ ​drugs​ ​or​ ​alcohol​ ​during​ ​the course​ ​of​ ​your​ ​session.

    3. That​ ​you​ ​provide​ ​me​ ​with​ ​the​ ​correct​ ​address​ ​of​ ​your​ ​online​ ​location.

    4. That​ ​the​ ​environment​ ​around​ ​you​ ​is​ ​safe​ ​and​ ​will​ ​remain​ ​distraction​ ​free.

    5. That​ ​you​ ​provide​ ​me​ ​with​ ​a​ ​phone​ ​number​ ​or​ ​other​ ​means​ ​of communication​ ​to​ ​contact​ ​you​ ​with​ ​in​ ​the​ ​case​ ​of​ ​a​ ​technology​ ​failure.

    6. That​ ​you​ ​provide​ ​me​ ​with​ ​a​ ​third-party​ ​emergency​ ​contact​ ​number.

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    Privacy GDPR Statement

    In line with the new regulations for the general data protection regulations I need to tell you what data I am collecting from you and what I intend to do with it.

    What data do I keep and why do I need it?

    Name and age – this is basic information that helps me get to know you.

    Address, email address, phone number – I use this as a way of contacting you regarding your sessions. I will mainly use the method you first contacted me on but if I cannot reach you, I will try a different method.

    Next of kin/ GP’s details – If I was worried that you were at risk then I may need to contact your next of kin or GP, if I can. I will let you know when/if I am going to do this.

    Session notes – I keep brief anonymous notes of our session(s), description of system they are kept in if appropriate.

    Will your data be shared?

    It is very unlikely that I will share your data. I will not sell it on or use it for unethical reasons. I may have to share it if my notes are subpoenaed by court, if you or anyone you tell me about is at harm or risk of harm I may have to pass this information on. I also have regular Supervision where I talk about my work but I do not use your name.

    How will I store your data?

    It is mainly stored as hard copy in a locked filing cabinet. Immediately after the work is finished, I transfer the data with your initials to my password protected computer. Your phone number(s) may be kept in my business mobile phone with your first name and last initial. Only I will access your information.

    How long will I store your data for and how will I dispose of it?

    I will keep Your session notes with your initials for 5 years.

    I will delete your phone number out of my mobile phone 3 months after our work finishes. Unless you have opted in for me to keep your mobile number and email address to receive further updates on workshops, newsletter or free downloads.

    Your Rights

    You can exercise certain rights in relation to your personal data that I process. These are set out in more detail at

    https://ico.org.uk/for-organisations/guide-to-the-general-data-protection-regulation-gdpr/individual-rights/

    Previous Clients completed work seen before 25th May 2018

    Your data will be deleted automatically as of 25th May 2018

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    Please note this is an important part of releasing the unwanted negative feelings or behaviours
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    Please be aware that should you choose to remain in the room it may affect the outcome of the session.
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    Please read additional policy for working via zoom/skype
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    By consenting to this you are allowing me to use your contact details to add you to my online guided programme while your child works with me. The details of this programme will provide you with some useful tools for yourself and understanding the RTT process to help and support your child.
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    Please select ALL the techniques when receiving Rapid Transformation Therapy as this forms part of the package.
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    Including the policy and privacy statement required in line with the new GDPR laws as on May 2018. (if no is selected I will be unable to work with your child)
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