Date

Referred by

Name

Birthdate

Address

City

State

Zip

Home Phone

Cell Phone

Email Address

Reason for your initial visit?

Emergency Contact #1 (Name, Phone number):

Emergency Contact #2 (Name, Phone number):

Have you seen a therapist for these or any other issues? Have you seen a therapist for these or any other issues? Yes No

Have you done EFT before? Have you done EFT before? Yes No

Have you worked with an EFT practitioner before? Have you worked with an EFT practitioner before? Yes No

If you answered yes, when?

How did you hear about me?

Are you currently under the care of a physician or mental health professional? Are you currently under the care of a physician or mental health professional? Yes No

Do you have or have you had any serious medical or mental health conditions? Do you have or have you had any serious medical or mental health conditions? Yes No

If so, please describe:

Are you taking any medications that may affect you mentally or emotionally? Are you taking any medications that may affect you mentally or emotionally? Yes No

Are you now or have you ever been suicidal, or have you attempted to hurt yourself? Are you now or have you ever been suicidal, or have you attempted to hurt yourself? Yes No

Do you have a history of sexual, physical, or emotional abuse? Do you have a history of sexual, physical, or emotional abuse? Yes No

How would you describe your childhood overall in a few sentences?

Are your parents living? Are your parents living? Yes No

What was your parents' relationship with each other and with you growing up?

Do you have siblings? Do you have siblings? Yes No

How many siblings?

What was your relationship with your siblings and what is it now?

Did someone other than an immediate family member live with you while growing up?? Did someone other than an immediate family member live with you while growing up?? Yes No

If so, describe your relationship with that/those person(s):

Do you believe in a God, Creator, Source, or Higher Power? Do you believe in a God, Creator, Source, or Higher Power? Yes No

If so, by what name do you call it:

Have you experienced anything in your religious or spiritual upbringing that you feel is interfering with your life now? Have you experienced anything in your religious or spiritual upbringing that you feel is interfering with your life now? Yes No

If so, please describe:

If you were to live your life over, what person(s) or event(s) would you prefer to skip?

What makes you angry and why?

When was the last time you cried and why?

Do any people or situations trigger a disproportionate reaction for you? (fear, anger, sadness, guilt)

What is your biggest regret or sadness?

Would anyone be uspset if you were completely healed? Would anyone be uspset if you were completely healed? Yes No

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