Personal Intake FormPlease fill out the form below prior to your scheduled appointment. Name * First Name Last Name Email * Subject * Message * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Primary Phone * (###) ### #### Emergency Contact * First Name Last Name Emergency Contact Phone * (###) ### #### Date of Birth * MM DD YYYY Occupation * Relationship Status * Single Married Separated Divorced Children * 0 1 2 3 4+ Other Member of Household * List any and all members of your current household How did you hear about EFT? Please select any issue you'd like to work on: * Divorce or Breaking Up Workaholic Stress or Anxiety Procrastination Fear or Phobias Chronic Pain Weight Issues Self Esteem Depression Grief Marriage Problems Business Performance Traumatic Memories Anger. Frustration, Resentment Sexual Problems Prosperity Lake of Joy Lack of Purpose Other If Other: Have you seen a therapist for any of these or other issues? * Yes No If yes, when? Have you done EFT before? * Yes No If so, when? Was it with a practitioner? Yes No If so, who? Doo you have a history of? * Check all that apply Epilepsy or Seizures Panic Attacks Asthma Severe Depression None of the above Have you ever felt suicidal? * Yes No If so, when and why? Do you have a history of substance abuse? * Yes No Are you taking any medications that may affect you mentally or emotionally? Yes No Do you have a medical or psychiatric condition I should know about? * If so, which? Did you grow up with siblings? * Yes No If yes, what was the birth order? Did you have a strong religious upbringing? * Yes No Any surgeries as a child? * Yes No Is there a situation, issue, memory or physical problem you would like us to start with? If you were to live your life over, what person or event would you prefer to skip? What makes you angry and why? When was the last time you cried and why? Do any people or situations trigger a disproportionate reaction (anger, fear, sadness, guilt) for you? * Yes No If so, who and/or what? What is your biggest regret or sadness? If our work together was amazingly successful, what would change for you? Who would be upset if you were completely healed? And why? What are three positive goals you would like to achieve? What strengths or positive qualities are you bringing to our work together? How would you like to feel at the end of the session? Informed Consent Form I, ______________________, understand that Amy Piper is not a licensed therapist, psychologist or health care practitioner and offers EFT (emotional freedom techniques) and Matrix Reimprinting as a self-help educator. * (enter name) I am aware that Amy Piper does not diagnose illness or disease, and does not prescribe medications. I agree not to discontinue or change any medications I am taking while working with Amy Piper without consulting my doctor. * (Please initial) I understand that EFT and Matrix Reimprinting are considered experimental procedures and are not a substitute for medical, psychological or psychiatric treatment or medications, and that it is recommended that I currently work with my primary caregiver for any condition I may have. * (Please initial) I understand that EFT and Matrix Reimprinting procedures may bring unresolved and distressing memories and related emotions and physical sensations into my awareness, and it is possible that disturbing material may continue to surface after a session and require further work. * (Please initial) I also understand that previously traumatic memories may lose their emotional charge and this could adversely affect my ability to provide convincing legal testimony. * (Please initial) I understand that all information I share with Amy Piper is confidential and that no information will be released to any third party without my express written consent, with the following exceptions: When there is imminent risk of danger to myself or another person; When there is suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse; When a valid court order is issued for session records; * (Please initial) I understand that Amy Piper has a 24-hour cancellation policy and agree to pay for any booked sessions that have not been canceled 24 hours in advance. * (Please initial) I agree to take complete responsibility for my own comfort, health and well-being while working with Amy Piper. I agree that typing in my name below is the electronic equivalent of my actual signature. * (Please initial) Client Signature * (typing your full name = consent) First Name Last Name Date Signed * MM DD YYYY Parent Signature (if under 18 yrs of age) * (typing your full name = consent) First Name Last Name Thank you! I'll be in touch shortly! I'm excited to help you find relief!
