Emotional release therapy intake assessment Please fill out the form below Name * First Name Last Name Preferred Pronouns Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Home Phone (###) ### #### Cell Phone Country (###) ### #### Date of Birth MM DD YYYY Gender * Male Female Status Married Separated Divorced Single Widowed Partnership I Live With Spouse Children Partner Friends Parents Alone Education Occupation in case of emergency, who should be contacted? Please include the persons name, their relationship to you and a phone number to contact them. How did you hear about Emotional Release Therapy? Have you worked with an Emotion Code Practitioner or experienced other energetic healing modalities? Yes No What are your major concerns / symptoms? Concern 1 Please describe the concern and when it began Rate your level of severity / distress / overwhelm / pain On a scale from 0 to 10, with 0 being no symptoms and 10 being most severe, rate the level of severity you are experiencing this complaint / symptom. Mark your rating below: 1 2 3 4 5 6 7 8 9 10 Concern 2 Please describe the concern and when it began Rate your level of severity / distress / overwhelm / pain On a scale from 0 to 10, with 0 being no symptoms and 10 being most severe, rate the level of severity you are experiencing this complaint / symptom. Mark your rating below: 1 2 3 4 5 6 7 8 9 10 Concern 3 Please describe the concern and when it began Rate your level of severity / distress / overwhelm / pain On a scale from 0 to 10, with 0 being no symptoms and 10 being most severe, rate the level of severity you are experiencing this complaint / symptom. Mark your rating below: 1 2 3 4 5 6 7 8 9 10 Concern 4 Please describe the concern and when it began Rate your level of severity / distress / overwhelm / pain On a scale from 0 to 10, with 0 being no symptoms and 10 being most severe, rate the level of severity you are experiencing this complaint / symptom. Mark your rating below: 1 2 3 4 5 6 7 8 9 10 Concern 5 Please describe the concern and when it began Rate your level of severity / distress / overwhelm / pain On a scale from 0 to 10, with 0 being no symptoms and 10 being most severe, rate the level of severity you are experiencing this complaint / symptom. Mark your rating below: 1 2 3 4 5 6 7 8 9 10 Do you experience any of the following? Depression Crying Feeling empty Physical aches & pains Fear Sleep problems Eating problems Stress (work) Stress (home) Mood swings Anxiety Anger Panic attacks Alcohol / drug use Memory problems Hormonal imbalance Relationship difficulties Limiting beliefs Phobia Allergies Or other? Please explain below What are your long-term health goals? Is there an area in your life you would like to see change and/or improve? (e.g. work, marriage, parenting)? Please describe: What is your desired outcome from today’s session? Please list past or present allergies, including allergies to medications: Are you currently pregnant? Yes No Do you have a heart condition? Yes No Do you have any of the following devices? Pacemaker Implanted Device Hearing Aid Insulin Pump None Please list your current and past health conditions, injuries, surgeries, or trauma that may be affecting your health now (e.g. diabetes, fibromyalgia, car accident, abuse, divorce, job loss): Is there anything else in your medical history, emotional history or past trauma that you consider to be relevant (even from childhood)? Is there anything else you would like to share that if improved upon could help you to feel more joy and fulfillment in your life? Anything else you feel I should know? Do you have any questions for me? Consent & Release of Liability * To indicate that you understand please tick the box. Please read here. I consent I have read and understand the below stated policies and will comply with them in all aspects. * To indicate that you understand our office policies before proceeding, please tick the box. Please read our Policies here. I confirm Thank you! You have completed your intake forms. We will be in touch soon.
