EFT for Weight Release Form Get Ready to transform your life! First Name Last Name Email Mobile Phone Birth Date Gender Female Male Relationship Status Single Married Divorced Widowed Occupation How did you hear about us? Friend/Relative Doctor Google Facebook Lecture Other Name of person that referred you Height Weight Goal Weight What's your experience with EFT/tapping? I have no idea what it is I've heard of it but never done it I've tried it a few times I'm an experienced tapper Why do you want to lose weight? What would you consider to be a successful outcome from the next 6 weeks of working together? How much weight would you ideally want to release? Is overeating an issue for you? Yes No Not sure If yes, how long have you been struggling with overeating? Is anyone else in your family overweight? If yes, who? Have you tried any other weight loss programs? If yes, which? How would you describe the suffering being overweight causes you? What is the biggest obstacle/challenge for you to lose weight? If you had to guess - what emotional or physical issue contribute to being overweight? Are there any specific foods/type of foods that you MUST eat - and you can't control yourself? Are there any specific times of day/situations/places where you MUST eat - and you can't control yourself? What happened the last time you reached your goal weight? What would you focus on if you didn't obsess about food anymore? If losing weight had a downside - what would it be? If staying overweight had a benefit - what would it be? If overeating were connected to an emotion which emotion(s) would it be for you? List medications, supplements you're taking (or enter "none" if none) List any major injuries or surgeries and when they took place (or enter "none" if none) Describe time and types of foods you eat for breakfast. Please include drinks (e.g. eggs, oatmeal, 7am) Describe time and types of foods you eat for lunch. Please include drinks : (e.g. salad, sandwich, 12 noon) Describe time and types of foods you eat for supper. Please include drinks (e.g. chicken, rice, vegetables 7 pm) Describe time and types of snacks you eat:. Please include drinks Anything else you think we should know about your weight release journey? Submit
