Intake Form

Name*

First

Preferred name

Name

Pronouns

E-mail address*

Telephone *

Address

Street, house number*

Zip code*

City*

Date of birth*

Occupation*

Name and telephone number of a contact person for emergencies*

What is the main reason for your session?*

Example: “Fears keep me from concentrating on my work. Money worries keep me up at night and keep me from being present with my friends and family. Etc.”

How long have you been suffering from this problem?*

When did you first notice it, and is there a particular event that you think contributed to how you feel today?

Describe how this issue is currently affecting your life.

Please describe in detail and with examples how it is noticeable in your life.

How big is the impact of this problem on your life? *

(1 = not at all; 10 = has a big impact on me)

Please tell me briefly about your childhood.

Refer to topics that you think may be related to your main problem.

What do you want most from your session?*

If I could grant you one wish, what would it be? Please be as specific as possible. You are invited to dream big and express bold wishes. The sky is the limit.

What would your life be like without this problem?*

Please describe specifically and in detail how you will feel, what you will do differently. How you will move differently in your everyday life. How do you interact with other people? How do other people react to your new being? Describe a small film of your life without this problem, so that we can both imagine it exactly. Important: write in the YOU form, as if someone were saying it to you, e.g.: you are self-confident and always find the right words when you have a challenging conversation.

On a scale of 1 to 10, how committed are you to overcoming your problem?*

(1 = not at all; 10 = fully committed)

How willing are you to listen to the audio recording every day? (1 = small; 10 = very large) *

As part of your session, you will receive a personal audio recording of about 20 minutes that you can listen to to internalize new thought patterns and behaviors. It is essential that you listen to the recording every day for 21 days.

Have you ever done therapy? If so, please provide brief details.

What medications are you currently taking? Please list.

Health problems (past and present). Please provide information in bullet points.

Do you have any clinically diagnosed mental health issues such as schizophrenia, epilepsy, bipolar disorder, or psychosis?*

Yes

If so, please briefly explain: what diagnosis and previous treatment.

Is there anything else you would like to share with me?

Please select how you would like to receive your personal audio hypnosis file. Only the password-encrypted variant protects your personal data. However, most clients would like to get the file directly on their mobile phone as easily as possible. This is only possible in unencrypted form *

Unencrypted on Signal

Unencrypted on Telegram

Password encrypted by email

Legal Notice and Informed Consent

1. Differentiation of the services offered

The services I offer in the field of coaching and rapid transformational therapy (RTT) do not constitute medical or psychotherapeutic treatment.
Services provided within the framework of my sectoral non-medical practitioner licence for physiotherapy serve exclusively for the treatment of complaints in the physiotherapeutic field.
Mental or psychosomatic illnesses such as depression are not diagnosed or treated. In such cases, it is recommended to contact a doctor, psychotherapist or appropriately qualified alternative practitioner.

2. Self-responsibility

I take full responsibility for my own actions during and after the sessions.
I acknowledge that neither coaching nor hypnosis or any other services offered guarantee any specific results.

3. Contraindications and health condition

I affirm that I have fully and truthfully provided all relevant information regarding my state of health.
I am aware that hypnosis is not suitable if I suffer from certain illnesses such as epilepsy, severe mental disorders (e.g. schizophrenia), neurological diseases, acute crisis situations or drug addiction. I will consult a doctor if I am unsure.

4. Disclaimer and Indemnification

I acknowledge that you are not liable for any direct or indirect damages, unless they are based on gross negligence or intent and within the limits of the applicable legal provisions.
Participation in meetings is voluntary and at your own risk.
I release Jasmin Peters from any liability and claims regarding my mental and/or physical well-being during and after the collaboration.
I also agree to indemnify Jasmin Peters from all claims, losses, liabilities, damages and expenses (including legal fees) arising out of my participation in the Professional Services.

5. Confidentiality and confidentiality

All personal and health information discussed in the context of the cooperation will be treated in the strictest confidence.
Exceptions apply in the following circumstances:
1. If I give explicit permission to break confidentiality.
2. If I am obliged to do so by a court.
3. When there is an acute danger to myself or others.
4. If minors (under 18 years of age) are affected.

6. Data protection

I have been informed that my personal data will be processed and stored in accordance with the General Data Protection Regulation (GDPR).
The data will be used exclusively for the documentation and implementation of the sessions and will not be passed on to third parties without my consent.
I have the right to receive information about my data at any time, to have it corrected, deleted or to have the processing restricted.
For requests regarding data processing or the revocation of my consent, I can contact the provider .
The data will be treated confidentially and deleted after completion of the cooperation, taking into account statutory retention periods.

7. Differentiation from promises of healing

I am aware that no promises of healing are made. The services offered do not replace medical, psychological or physiotherapeutic diagnosis or treatment.
Neither a cure nor an alleviation of symptoms is guaranteed.
I confirm that in case of complaints that require medical or psychotherapeutic treatment, I will consult an appropriate specialist or therapist.

8. Explanation of the accuracy of my information

I answered all questions and background information during the first consultation and/or therapy session accurately and truthfully.
I confirm that I [Ihr Name] have informed about any clinically diagnosed mental illness such as schizophrenia, epilepsy, bipolar disorder or psychosis.
I undertake to truthfully communicate all relevant information in future meetings as well.

9. Governing Law and Jurisdiction

These Terms and any disputes arising from them shall be governed by German law.
The place of jurisdiction is the District Court of Hamburg-Altona.

10. Consent to participate

I have been informed about the process, the mode of action and possible risks of the services offered and I agree to participate.
I am aware that I can break off the cooperation or revoke my consent at any time. However, services already provided will be invoiced.

11. Use of anonymized case studies (optional)

To give more people access to the content and topics of my work, I can use anonymized and generalized case studies from sessions on social media or in my newsletter.
This content is presented in such a way that no conclusions can be drawn about my person or my case.
The aim is to make the content and working methods more tangible to other people using examples.

I agree to the anonymized use of content from my sessions.

(optional)

Declaration of consent

I have read, understood and accept the above legal notices.

I consent to the processing of my personal data in accordance with the GDPR.

By clicking on the checkbox, I agree to the legal information and the privacy policy. Without this consent, the cooperation cannot begin.

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