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):

To what extent are any of the following issues currently affecting you on a scale from 0-10? (0 means not at all and 10 means it affects you extremely):

Stress or Anxiety: Stress or Anxiety:012345678910

Anger/Frustration/Resentment: Anger/Frustration/Resentment:012345678910

Guilt/Shame: Guilt/Shame:012345678910

Grief/Sadness: Grief/Sadness:012345678910

Procrastination/Lack of Motivation: Procrastination/Lack of Motivation:012345678910

Low Self-esteem: Low Self-esteem:012345678910

Performance Issues: Performance Issues:012345678910

Fears or Phobias: Fears or Phobias:012345678910

Relationship Challenges: Relationship Challenges:012345678910

Painful Memories/Past Traumatic Experiences: Painful Memories/Past Traumatic Experiences:012345678910

Physical Pain/Physical Symptoms: Physical Pain/Physical Symptoms:012345678910

Cravings/Addictions: Cravings/Addictions:012345678910

Major Losses Experienced: Major Losses Experienced:012345678910

Self-Sabotage: Self-Sabotage:012345678910

Other issues not mentioned above Other issues not mentioned above012345678910

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

How did you hear about me?

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?

Please select to confirm: Please select to confirm: I (client) have provided the correct information and acknowledge reading through the contents.

Please select to confirm: Please select to confirm: I (client) have read and agree to the EFT, Disclaimer, Confidentiality, Liability, and Informed Consent.