ICM Case Study - Transformation Program Intake Form

INNER CHILD MATRIX (ICM)

CASE STUDY TRANSFORMATION

PROGRAM - INTAKE FORM

Please fill in the form below so that we can figure out the best way to support you.

*mandatory field, please fill in.

First Name *
Last Name *

Date of Birth ( Please select the right format, eg 15-01-1976) *

E-mail to contact you *

Phone Number to contact you *

Current City for Time Zone *

Current Country *

Relationship status *

Profession, for eg trainer, home maker *

Preferred Language for Sessions *

Other Languages for Sessions *

How did you find out about our Case Study Program? *

1. What are the areas you would like to explore during your transformation program? For example, problems you would like to solve or heal, any goals you desire or outcomes you want. *

2. What are the 3 most important changes you would like to make in your life? *

3. What prevents you from making these changes? *

4. Answer only if relevant: What have you done so far to solve the problem or reach the goal or outcome? What has worked and what has not worked?

5. How will you know you have made these changes? *

6. What are the priorities you would like to focus on during the transformation program? (list top 3 in order) *

7. What are your expectations from your coach/practitioner ? *

8. On a scale of 1 to 10 how committed are you to achieving the results and changes you desire? (10 being fully committed, 1 being not at all) *

9. Any other information (for example information from medical professionals and healthcare specialists) *

10. Would you be comfortable with us creating a private WhatsApp Group between you and the internal team of Vitality Living College? *

YesNo

11. ICM Practitioner in Training I want to work with:

If you have a preference for the ICM Practitioner in Training you want to work with, you can just type their name above. Here are the list of ICM Practitioners in training. We cannot guarantee that they will be available, however we will do our best to get you connected or find you the best fit. You can also leave the below blank and let us match you up with the ICM Practitioner in Training.

Submission of this form means that you have read, understood and agree to these guidelines and terms.

In summary:

• Disclaimer: You agree to treat the sessions as emotional therapy and not medical/mental health treatment.

• Confidentiality: You & your practitioner agree to keep the session(s) confidential.

• Record Taking Consent: You agree that your sessions might be recorded and shall be kept confidential.

• Informed Consent: You agree to provide informed consent for consultation calls and therapeutic sessions with EFT.

• Data Information and Privacy: Your sessions are private and are governed by our Privacy Policy and Data Protection Declaration.

• Indemnity: You agree to keep VLC harmless from the acts of the Practitioner

• Dispute Resolution: In case of any dispute, we shall amicably settle such disputes between each other, unless the need to take some legal measures arises.

• Contact: If you have any questions about your session or the above information, please contact us on [email protected].

Yes I understand *

Full list of certification training and seminars

We would love to connect:

+919920454749 (India), +919820974625 (What's App)

[email protected]