EFT Intake 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 Best days and times of day to work with me Describe what you would like us to help you with Recently the condition has: Not Changed Worsened Improved I specifically want to accomplish: How would that create a difference for you now? What would it give you or allow you to do that you cannot do now? What's the most urgent or pressing part of this desired change? What would you consider to be a "success" from our work together? For example - I'd feel better about... ,I'd be less afraid to... , I'd feel more peaceful about How long have you had this issue/situation? What other methods have you tried to fix this situation? Thinking of this situation right now, how could you describe the suffering it causes you? If you had to guess - what emotional or physical issue might have helped create this situation? What have you noticed makes the pain or situation better? Have you noticed this pain or reaction in other situations? If yes - when? What 5 life events still bother you the most? (events are specific times when something happened... to you) For Example: The time when Jeff said he was leaving. Is there anything in your life you’d have liked to have skipped? List medications, supplements you're taking (or enter "none" if none) Do you have any DSM V or other medical diagnosis I should be aware of List any major injuries or surgeries and when they took place (or enter "none" if none) Anything else you think we should know about the problem you are seeking help with Submit
