New Client Intake Form

In order to ensure my level of training and competence is appropriate to support you, and in case of an emergency, I will need you to fill in this form before scheduling an appointment. Everything will be kept confidential within the bounds set forth in the forms that you are required to sign before we begin sessions together.

If you would prefer to download it and fill it out, please click the button to download the PDF.

New Client Intake

Have you seen a therapist for these or any other issues?

Have you done EFT before?

Have you worked with an EFT practitioner before?

Are you currently under the care of a physician or mental health professional?

Do you have or have you had any serious medical or mental health conditions?

Are you taking any medications that may affect you mentally or emotionally?

Are you now or have you ever been suicidal, or have you attempted to hurt yourself?

Do you have a history of sexual, physical, or emotional abuse?

Are your parents living?

Do you have siblings?

Did someone other than an immediate family member live with you while growing up??

Do you believe in a God, Creator, Source, or Higher Power?

Have you experienced anything in your religious or spiritual upbringing that you feel is interfering with your life now?

Would anyone be uspset if you were completely healed?

Please select to confirm:

Please select to confirm:

Please read before agreeing above: Description of Services and Disclaimer.