Client Intake Form

The more information you provide, the more prepared I will be and the better I can serve you. If you have any questions at all please feel welcome to call and clarify prior to submitting this form.

Evie's direct number: +61 412 005 357

Full name (including minors)

Preferred name

Contact number

Email‍‍‍

Residential address

Postal address (if different from residential)

DOB or age range

8 - 11

12 - 15

16 - 18

19 - 29

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30 - 39

40 - 49

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50 - 59

60 - 69

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70 - 79

80 +

Relationship status

Religious or spiritual orientation

Emergency contact

Emergency contact's number

Relationship

If your contact person does not live close to you, please nominate a person below who does. This support person may be used as a secondary emergency contact.

Support person

Support person's contact number

Relationship

Personal circumstances:

Please tick if you have a history of

Epilepsy or seizure

Schizophrenia

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Panic attacks

Clincal depression

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Anaphylaxis

Further detail (if required)

Are you feeling suicidal? Or have in the past?

If so, when and / or why?

Please list any medications or other substances that may affect you mentally or emotionally?

Are you involved in any legal proceedings wherein you may be required to testify? (If this changes during the course of our relationship it is important to advise immediately.)

Level of experience in EFT (tick all the boxes that describe your experience).

I've never done it. I don't even know what it stands for.

I've never done it, but I've heard about it.

I've copied what friends have shown me.

I've tapped along with professional demonstrations.

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I tap by myself when I need to.

I've tapped with a practitioner before on my own issues.

I'm (working towards being) a certified practitioner in Clinical EFT.

Let's get down to business.

Tick the issues that are currently most pressing to you.

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Other

Of the selected, which takes priority?

List any other strategies used to address this issue in the past.

When feeling "centred" or "good," what three emotions does that feel like? (e.g. peaceful, excited, energised, strong, confident, loving, etc.)

Is there anything else you want to tell me?

How did you find out about Evie?

Referral from someone I know

Facebook

Internet search

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Tapping Solution

EFT University

Other

Client intake form

By submitting this form I declare that I have read and fully understand this Intake Form. All answers are true and correct to the best of my knowledge. I recognise that I have the opportunity now and in the future to discuss any questions I have. I agree to and accept EFT services from Eve Soemardi and voluntarily submit this information.

For legal guardians of minors only: (minors are those under 18 years of age)

I declare that I am the legal guardian of the child registered on this form as the client and grant permission for EFT sessions with Eve Soemardi. In the interests of my child gaining the most benefit, I waive my legal right to their information so they can develop a trusting relationship. I understand that I can still gain general feedback under these conditions.

Full name of parents or legal guardians of minors:

Date

Verification process on submitting this form

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Client Intake Form

Client intake form - Details