First Contact Intake Form Name: Date: Address: City: Zip: Telephone: Email: Date of birth: Emergency contact: Occupation: Relationship status: Children: Please, let me know how you heard about me: Below, select all the issues you would like to work on. Divorce or breaking up Stress or anxiety Fears or Phobias Weight issues Procastination Chronic pain Depression Traumatic memories Workaholic Self esteem Grief Marriage problems Sexual problems Business performance Anger / Resentment Lack of joy Prosperity Lack of purpose Issues not mentioned above: Have you seen a therapist for any of these or other issues? If yes, when? Have you done EFT before? If yes, was it with a practitioner? Do you have a history of: Epilepsy or seizures? Panic attacks? Severe depression Are you taking any medications that may affect you mentally or emotionally? Do you have a medical or psychiatric condition I should know about? Did you grow up with siblings? If yes, what was the order? Did you have a strong religious upbringing? Did you attend religious school? Any surgeries as a child? Is there a situation, issue, memory or physical problem you’d like us to start with? 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? Do any people or situations trigger a disproportionate reaction (anger, fear, sadness, guilt) for you? What is your biggest regret or sadness? If our work together was amazingly successful, what would change for you? Is there anyone who would be upset if you completely healed? What are three positive goals you would like to achieve?
