Form | EFT Serenity

Client Intake Form

Date

Name

Contact Number

Residential Address

Postal Address (if different)

Age

Occupation

Relationship status

Emergency Contact Name & Relationship

Primary Doctor Information

Is there anyone else in your support network who you would like me to have access to in a time of need?

What is your main goal in working together?

If you reach this goal, how would your day-to-day life change?

Ideally, how would you think, act, and feel?

How possible does this ideal feel right now? Rate 0 = not possible, 10 = it's already true.

What are the main 1-3 issues you hope to release?

What daily or weekly events make this issue worse?

What is blocking you from reaching this goal?

What prompted you to reach out now?

What have you tried that has helped with these issues/goals?

What have you tried that did not help?

Have you seen other practitioners for this issue/goal? If yes, what was helpful vs. not helpful ?

Are there any significant life events (even very young) that you feel relate to these issues?

Do you have a history of epilepsy? IMPORTANT: Clients with a history of epilepsy or psychotic episodes should only have an EFT session while under direct supervision of a doctor or therapist.

Are you involved in any legal proceedings wherein you may be required to testify? IMPORTANT: If this changes during the course of our relationship, it is important to advise immediately.

Is there anything else you would like to share that I did not cover in my previous questions?

I have read and fully understood this document. All answers are true and correct to the best of my knowledge. I recognise that I have the opportunity now and in the future to discuss any questions that I may have. I agree to accept the EFT services from Lisa Reardon and am voluntarily submitting this form.

CONFIDENTIALITY. I understand that I am entitled to confidentiality with certain exceptions in which reporting may be legally required, such as current abuse of a minor, elderly, or disabled person, or the threat of serious bodily harm to myself or others. Confidentiality may no longer be legally protected should a judge make a court order to Lisa Reardon to release certain information. I have been advised to consult with an attorney if I am involved in a legal situation in which such confidentiality may be at issue.

CONSENT. Emotional Freedom Techniques (EFT tapping) are not used to diagnose, treat, cure, or prevent any physical or psychological illness or mental health disorder. Consequently, Lisa Reardon’s sessions and resources do not provide medical diagnoses, nor do they offer cures. EFT is considered complementary or adjunct treatment options; therefore, they do not replace health care treatment from medical professionals. Emotional Freedom Techniques draw from acupuncture, cognitive reframing, exposure therapy and other time-honoured approaches to healing. Subtle energies and gentle stimulation of meridian points via tapping while focusing on emotional issues is believed to reduce stress hormones in the body, thus returning the body to a state of balance. EFT is a form of gentle self-help methods used to release and resolve physical and emotional distress by clearing blocks in the body’s energy system. There have not been reports of distressing side effects when EFT is administered by a qualified practitioner, but this statement does not mean that you will not discover negative side effects for yourself. If you do experience side effects, you commit to notifying Lisa Reardon and taking the best course of action. I understand that clients having a history of epilepsy or psychotic episodes should only have an EFT session while under direct supervision of a doctor or therapist. These techniques may bring to the surface issues and memories that need addressing, perhaps ones you were not aware of before the client-practitioner relationship began. If this happens, you agree to inform your practitioner as soon as is reasonable. Your consent to use these techniques involves your voluntary agreement to take full responsibility for your well-being, progress, and behaviour and to indemnify practitioner, Lisa Reardon and her company EFT SERENITY. While Emotional Freedom Techniques that have produced remarkable clinical results and are gaining scientific support, they are not replacements to Psychiatric, Psychological or Medical treatment. As we work together there is no guaranteed outcome in any individual or individual session. Sessions are a time to engage with and learn tools to address the emotional side effects of triggering events.

BILLING & PAYMENT. The client understands that payment in advance is required on booking payment.

CANCELLED/MISSED/LATE APPOINTMENTS. Single sessions: I understand that full payment will be required for missed sessions and sessions not cancelled more than 24 hours in advance. Bundle sessions: I understand that once I have agreed to a session time, cancellations or changes must be made more than 24 hours prior or I forfeit the session. I understand that if Lisa has to reschedule my session for any reason, I will be flexible to reschedule within 2 weeks from when it was originally scheduled (unless medical conditions prevent Lisa from doing so, in which case you may request a refund.) You can receive a refund if you cancel with more than 24 hours’ advanced notice or if we agree that you were unable to attend due to circumstances outside of your control. If you are late, we will still end on time. I understand that it is important for me to respect the booked session times and that Lisa will do the same. If I am late for my session, the session time will not be extended by the amount of time I am late. I understand that if Lisa is late for my session, the session time will be extended accordingly or the extra time will be added to a future session by prior arrangement if we do not have time to extend the session she was late for.

I acknowledge that I have read and understand the above statements regarding EFT and discussed concerns with Lisa Reardon. Therefore, I consent to EFT freely and without duress of any kind and agree to indemnify and hold harmless Lisa Reardon, information on their website, and resources they share, from any claim, action, loss, liability, damage or suit, arising from my participation and use of the information and techniques.

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