New Client Form

Emotionally Free Client Form

We ask all our new clients to fill out a New Client Form for several reasons. One, we need this for administrative and legal purposes. Two, we would like both you and us to be as prepared as possible before you come to see us, so that we can spend less time getting ready and as much precious time as we can during the session doing the clearing and coaching work. This way you can get the most benefit out of our sessions together. Please fill this out at least two hours before coming to see us.

Contact details

* Indicates required field

Name *

First

Last

If under 18, name of parent / guardian *

Email address *

Skype user name *

Preferred phone number *

LivingSocial Redemption Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

How did you find out about us and our services? *

About you

Date of birth *

Gender *

Do you have any current health concerns? *

Yes No

Please tell us about your health *

Are you presently, or have been under the treatment or a Psychiatrist, Psychologist or Doctor? *

Yes No

If yes, please list name of health care practitioner and describe *

What are you spiritual / religious beliefs if any? *

Goals / Outcomes / Reasons for working with us

Please describe what you would like to gain from our work together *

Desired Outcome / Goal (1) *

How I feel without it (1) *

Related emotions (1) *

How I will feel when I have it (1) *

Desired Outcome / Goal (2) *

How I feel without it (2) *

Related emotions (2) *

How I will feel when I have it (2) *

Desired Outcome / Goal (3) *

How I feel without it (3) *

Related emotions (3) *

How I will feel when I have it (3) *

Summary of significant / formative events

Ages 0-7 (Imprint period) *

Ages 8-14 (Modelling period) *

Ages 15-21 (Socialising period) *

Other comments

Is there anything else you would like us to know? *