Name
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First Name
Last Name
Email
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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(###)
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Date of Birth
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Emergency Contact
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What services are you interested in?
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Occupation
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Relationship Status
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Children
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Other Members of Household
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Please let me know how you heard about me
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Please mark all the issues you would like to work on.
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Issues Not Mentioned Above
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Have you seen a therapist for any of these or other issues? If so, when?
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Have you done EFT before? If so, with a practitioner? Who?
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Do you have a history of:
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Mark all that apply
Are you currently feeling suicidal?
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Have you ever felt suicidal or made an attempt?
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If yes, when? And why?
Do you have a history of substance abuse?
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Are you taking any medications that may affect you mentally or emotionally? If so, what are they?
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Do you have a medical or psychiatric condition I should know about?
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Did you grow up with siblings? If yes, what was the birth order?
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Did you have a strong religious upbringing? Catholic school?
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Any surgeries as a child?
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Is there a situation, issue, memory or physical problem you'd like to start us with?
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If you were to live your life over, what person or event would you prefer to skip?
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What makes you angry and why?
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When was the last time you cried and why?
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Do any people or situations trigger a disproportionate reaction (anger, fear, sadness, guilt) for you?
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What is your biggest regret or sadness?
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If our work together was amazingly successful, what would change for you?
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Who would be upset if you were completely healed?
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What are three positive goals you would like to achieve?
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What strengths or positive qualities are you bringing to our work together?
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How would you like to feel at the end of the session?
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Additional Info
Anything else you'd like us to know?