Intake Form Please fill this out prior to your first session 3 Intake Form Name * First Last * Last Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Cell Phone * Home Phone Skype Email * Emergency Contact Name * Emergency Contact Phone * Date of Birth * Occupation * Relationship Status * Single Married Open Prefer not to say OtherOther Children * YesNo If Yes, how many & ages? Other members of household: How did you hear about me? * Referral Word of Mouth Google Search Social media OtherOther Please check all of the issues you would like to work on: * Divorce or Breaking Up Workaholic Stress or Anxiety Procrastination Fears or Phobias Chronic Pain Weight Issues Self Esteem Depression Grief Marriage Problems Business Performance Traumatic Memories Anger, Frustration, Resentment Sexual Problems Prosperity Lack of Joy Lack of Purpose OtherOther Have you seen a therapist for any of these or other issues? * YesNo If so when and for what? Have you done EFT before? * YesNo If so, when and with whom? Do you have a know history of any of the following? * Epilepsy or Seizures Panic Attacks Asthma Severe Depression Are you currently feeling suicidal? * NoYes Have you ever felt suicidal or made an attempt? * NoYes If so, when and why? Do you have a history of substance abuse? * NoYes Are you taking any medications that may effect you mentally or emotionall? * Do you have any medical or psychiatric conditions I should know about? * Did you grow up with siblings? * YesNo What is the birth order? Did you have a strong religious upbringing? * NoYes Did you got to Catholic School? * NoYes Did you have any surgeries as a child? * If you were to live your life over, what person or event would you prefer to skip? * What makes you angry and why? * When was the last time you cried and why? * What is your biggest regret or sadness? * If our work together was amazingly successful, what would change for you? * Who would be upset if you were completely healed? * What are three positive goals you would like to achieve? * What strengths or positive qualities are you bringing to our work together? * How would you like to feel at the end of the session? * What issue would you like to start with in our first session? * Please include any memories that you think are involved. When did it start and what was going on at the time? Please download & sign this Informed Consent Form. You may upload it below, or bring it to your first session. Looking forward to getting started! File Upload Drop a file here or click to upload Choose File Maximum file size: 516MB Submit Δ
