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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

I realise that, after I click the below "Submit" button, I need to scroll up and complete the Recaptcha verification process that will feature above.

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Option 1

Option 2

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Option 1

Option 2

Submit your basic details

Submit your personal circumstances

Provide your informed consent

If you are engaging services on behalf of a minor in your care, there is a fourth form you are required to complete. Please do so now.

Parental and guardian consent

To confirm your booking please prepay for your session. Fees feature below.

Bank: Queensland Country Bank BSB6: 654 000 Account: 64199815 Name: Lux Fons Association

Please use your name as your reference.

Please provide confirmation of payment to Evie.

Once all forms and payment have been submitted Evie will confirm your appointment.

Evie's direct number: +61 412 005 357

Clinical EFT - extended session

Duration: 1 hour and 20 minutes

Amount: $140 AUD / $120 USD

Delivery: Online or in person

Recommended for first timers

Online services are usually facilitated over Zoom. On the day of the appointment I will email you a zoom link and passcode. If you have not downloaded Zoom before please do so at https://zoom.us/support/download

In person services are held at Evie's private dwelling in Witta. An address will be provided once booking has been confirmed.

Clinical EFT - standard session

Duration: 1 hour

Amount: $100 AUD / $85 USD

Delivery: Online or in person

Recommended for returning clients

Online services are usually facilitated over Zoom. On the day of the appointment I will email you a zoom link and passcode. If you have not downloaded Zoom before please do so at https://zoom.us/support/download

In person services are held at Evie's private dwelling in Witta. An address will be provided once booking has been confirmed.

Multi Session Package - recommended

Duration: 3 x 1 hour and 20 minute sessions (4 hours in total) OR 4 x 1 hour sessions (4 hours in total)

Amount: $350 AUD / $300 USD

Delivery: Online or in person

Recommended for those who want to dig deep and address the fundamental causes behind their pain.

For those who would like to go deep, EFT is most effective when work is done over an extended period of time. While clients often feel better after one session, they miss a golden opportunity to truly release themselves from trauma by digging deep and tying up loose ends beyond their immediate trigger (which is possible but not probable in one session). A package of three sessions over time allows for a deep and thorough exploration of why one becomes triggered, and opens up the possibility of addressing the wound at it cause.

Payment must be made upfront when booking the first appointment.

Online services are usually facilitated over Zoom. On the day of the appointment I will email you a zoom link and passcode. If you have not downloaded Zoom before please do so at https://zoom.us/support/download

In person services are held at Evie's private dwelling in Witta. An address will be provided once booking has been confirmed.

ONLINE Learn how to tap!

Duration: 25 minutes

Amount: $50 AUD / $42 USD

Delivery: Online only

Great session to learn the process

Receive a quick one-on-one orientation with Evie to learn about the tapping points and set-up statement and start your own EFT journey. Ask questions and receive a PDF of EFT at a glance to assist while you learn this amazing destressing technique.

Online services are usually facilitated over Zoom. On the day of the appointment I will email you a zoom link and passcode. If you have not downloaded Zoom before please do so at https://zoom.us/support/download

PHONE Get in the zone call

Duration: 15 minutes

Amount: $30 AUD / $25 USD

Delivery: Phone only

Recommended when preparing for an important event

REGULAR CLIENTS ONLY: Need to make an important announcement, phone call, or presentation? Going to an important meeting? Book in a 15 minute tapping session via phone with Evie to reinforce the appropriate mindset just before your event.

Once confirmed Evie will call you at the agreed time to assist you in preparing for your important event.