Client Consent Form

Name

First Last

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Nature of problem:

Allergies & sensitivities:

Lifestyle issues:

Do you smoke?

Yes
No

How many units of alcohol do you enjoy per week?

Work stress levels

Physical conditions:

Emotional condition:

Family situation:

Names of 4 people important to you

3 memorable events with negative emotional charge

Are you seeing Doctor for any issues?

Any mental health diagnosis?

Do you have epilepsy?

Yes

Prescription medication?

Desired outcome of work

Consent*

I have read and understand the disclaimer

I understand that no medical claims are made as to the effectiveness of this technique for my particular issue(s). I note that EFT Coaching is not a substitute for medical diagnosis and treatment, or psychological diagnosis. I understand that EFT Practitioners do not diagnose conditions, prescribe or perform medical treatment, prescribe substances, nor interfere with the treatment of a registered medical professional. I understand that some of my issues that we will be working on may consist of many aspects and may take some time and persistence to achieve the desired outcome.

Terms*

I agree to the Privacy Policy and understand my data will be stored for future correspondence

Signature

Date

CAPTCHA

Comments

This field is for validation purposes and should be left unchanged.

LET'S CONNECT

On Facebook

On Instagram

Via
Email

Client Consent Form

LET'S CONNECT

On Facebook

On Instagram

ViaEmail

Via
Email