Name

First Name

Last Name

Have you had EFT tapping before?

Yes

Do you have any mental health diagnoses? Please list and when diagnosed.

Are you on any medications? If yes, please just list medication names.

Are you involved with any talk therapy with a therapist? If yes, list their name and contact information.

Do you have a primary care physician? If yes, please list their name and contact information.

Are there any other medical conditions that have not been listed? If yes, please list medical conditions and if you are still being treated for them.

Are there any other modalities that you are using for treatment for any conditions listed above? If yes, please list the modalities and how often it is used.

What is your goal for today? What do you want to focus on for the session?

On a scale from -10 to 10, where would you rate how you have been feeling on average.

-10 meaning, 0 feeling nothing, and 10 feeling great

Why do you think you have been feeling this way? Please briefly describe below.

Consent

I understand that EFT Tapping is a simple, gentle energy technique that is used for stress reduction, anxiety relief and relaxation. I understand that EFT practitioners do not diagnose conditions nor do they prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a licensed medical professional. I understand that EFT Tapping does not take the place of medical care. It is recommended that I see a licensed physician or licensed healthcare professional for any physical or psychological ailment I may have. I understand that EFT Tapping can complement any medical or psychological care I may be receiving. I also understand that the body has the ability to heal itself and to do so, complete relaxation is often beneficial. I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to come to a state of balance. I understand that no information about any client will be discussed or shared with any third party without written consent of the client or parent/guardian if the client is under 18. Please type your name below.

Date

YYYY

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