Intake From

Please take a few minutes to complete the form.

    Your Name

    Date

    E-mail

    Phone Number

    Age

    What would you like to address?

    When did the problem start?

    Is this the first time you have felt challenged with this problem?

    What is your realistic ideal outcome of this session?

    Person to contact in emergency?

    Are you taking any medications to support your mental health?

    List your main concerns in order of importance?

    Do you have any questions for me?

    INFORMED CONSENT

    1.WHAT IS EFT (EMOTIONAL FREEDOM TECHNIQUE)

    EFT (Emotional Freedom Technique) is a quick and simple method of reducing the intensity of traumatic memories. We tap on the acupoints, the endpoints of meridians while saying statements about our problem. We include how we feel, think, and perceive things through sensory perceptions. So, while we tap, we honestly express how we feel/think about the problem.
    Stimulating these acupoints reduces limbic arousal in our brains. In addition, it sends a calming signal to the amygdala, which is primarily involved in processing emotions and memories associated with fear and turning this fear response off.
    As a result, cortisol and other stress chemicals are not released; instead, it develops brainwaves that reduce fear, and we experience a state of relaxation.
    Tapping works with all sorts of issues: physical issues, emotional issues, bad habits, repeating cycles, and beliefs that no longer serve us, to name a few.

    2. DISCLAIMER

    My services are not a substitute for the diagnosis and/or treatment of medical or mental health conditions. I do not diagnose or treat medical or mental health conditions, nor am I licensed to do that. The client also understands that the services provided are not intended to prevent, cure, or treat any mental disorder or medical disease that would require the intervention of a trained psychiatrist or medical provider.

    3. SCOPE OF PRACTICE

    The coach/facilitator will not determine what I should or should not do and will make no choices for me. Instead, the coach/facilitator will offer questions and guidance within particular exploratory models with the intent to for me find my own answers through my own inner guidance and wisdom.

    The coach/facilitator is not and will not be liable or responsible for any actions, inaction, or direct or indirect results of any services provided. Implementing any choices is exclusively the client's responsibility. The client's exclusive responsibility is also to seek appropriate independent professional, medical, or psychiatric guidance or services if needed.

    4. PROFESSIONAL RECORDS

    I keep brief records on each session, primarily noting the date of the session, the obstacles, and the progress in relation to your goals. I maintain your records in a secure location that can not be accessed by anyone else.

    I will maintain your record for three years after our last contact, after which I may securely dispose of them.

    I understand that both parties may terminate and discontinue the coaching relationship at any time if deemed adequate by any of the parties.

    5. CONFIDENTIALITY

    You have the absolute right to the confidentiality of your therapy. Therefore, I can not and will not tell anyone else what you have told me or even that you have sessions with me with the exceptions defined/expected by law.

    I may occasionally find it helpful to consult other professionals about a case. During a consultation, I avoid revealing my client's identity. The consultant is also legally bound to keep the information confidential.

    6. FEES

    Current fees and length of the session are on the website. Cancellations must be made at least 24 hours in advance, or else the fee will be charged.

    7. OTHER PROVISIONS

    I understand, acknowledge, and accept the coach/facilitator's current level of experience, training, and credentials.

    My signature below indicates that I have read the information in the document, understood it fully, have discussed any questions or matters with me and/or others, and agree to abide by its terms during our professional relationship.

    Signature

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