Intake Form

Personal Details

Date (required)

Name (required)

Email (required)

Address (required)

Daytime Phone (required)

Emergency contact and Phone (required)

Date of Birth (required)

Age (required)

SingleMarriedLiving withWidowedSeparatedDivorced Marital Status

Number of children

Occupation

Hobbies/Recreation

By who were you referred?

Health Details

List all physical/emotional complaints

Briefly describe the health concern(s) you would like to address in this session. Note when it began, and if there was any trauma at the onset. Rate the severity on a scale of 0 (nonexistent) to 10 (all time worst)

What do you feel caused this problem?

What other approaches have you tried for the problem(s) and how well did they work?

Are you currently in a course of treatment (doctor, therapist, alternative health care, etc.)? List medications taken and what they’re for:

Please list any chronic condition - headaches, indigestion, insomnia, allergies, etc.

What is your daily intake of:
Pure water
Soft drinks
Fruit juice
Tobacco

On a scale of 1-10 what is your daily vitality?

Do you experience any physical pain you haven't already mentioned? If yes, explain:

List history of accidents, injuries, surgeries, major illness (with dates)

Any other information you feel may be pertinent to your session?

Dear Client,

Thank you for taking an interest in EFT. Before we can begin our work together, Please note the following:

While EFT has reportedly produced remarkable results in clinical trials, it is still considered to be in the experimental stage. I have not conducted or participated in any of these clinical trials. Although I have conducted my own research, and I personally believe the results of the clinical trials to be accurate, I have no independent knowledge or information to prove the accuracy of the claimed results.

I am not a licensed mental health professional. The information and coaching I provide is intended to educate and inspire you on your personal journey towards an ever- increasing state of well being in all aspects of your life. The services that I provide are designed and intended to give you the tools to make informed decisions about your lifestyle and health. Although my coaching may prove valuable to help you reach your goals and overcome physical and emotional obstacles, it is not intended to replace care that is best provided by a qualified health professional. Nothing I say or do is intended as medical advice, diagnosis, or treatment. My services should not be used as a substitute for any treatment that has been prescribed or recommended by your doctor.

If you are under the care of a health professional, or if you should be under such care, I recommend that you discuss modifications in your diet, lifestyle, exercise program, nutrition, or use of EFT with your health professional prior to making any changes. I also recommend that you never discontinue or reduce prescription medications that you are taking, or that you should be taking, without first consulting your doctor or pharmacist. You must take complete responsibility for your physical and emotional well-being

By checking the box below, I confirm that:

1. I have read and I understand this waiver

2. That I choose to voluntarily participate in the EFT process

3. This waiver now and forever releases Marc Hammond, his associates, contractors employees, successors and assigns, of any and all claims that may, or which could arise, in connection with the services provided, or to be provided by him.

This includes personal injury, accident, and or for any physical, mental, or condition that may result from work done on and with me. This document once signed by me may be submitted electronically, or via facsimile, and any copy hereof may be accepted and treated as if it were the original hereof.

Accepted and Agreed:
_{EFT and Emotional Freedom Techniques are registered trademarks of Gary Craig, and are used with permission.}

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