Confidential Client Intake Form

Include what's involved if appropriate.
Include when last visited & why
Medical & integrated health e.g. massage, aromatherapy, EFT, EMDR, nutrition etc
Use & Consumption
Accidents, operations, natural disasters etc.
When? Gender of Therapist? What type? How long for? Why did it stop? What did you find useful about it? When it stopped, what was this like for you? Did you get what you wanted from it? What did you find unhelpful about it?
These are all detailed below at the bottom of the page.
I completely understand that you, Mary Jane Newman, are not a medical doctor, and that these sessions do not replace the advice of a physician. I understand that your advice is not meant to conflict with the recommendations of doctors or practitioners who are licensed . I understand that I have the right to choose alternative methods of health treatment for myself, and that if I do so, I accept full responsibility for my actions. I understand that you or the processes that you guide me through, do not diagnose or treat medical problems, nor does Meta-Health, EFT, Matrix Reimprinting, or any other tool that you show me replace the need for medical attention or substitute for professional mental health care. META-Health is the stress related diagnostic tool that works alongside medical diagnoses. I fully understand that you recommend that I visit a licensed physician or mental health counsellor/psychiatrist if I have a serious physical or mental health problem and that I should consult with my physician or nutritionist before I make any changes in my diet. I understand that you do not advocate the discontinuance of any prescribed medication. I have read this informed consent and understand it. I am here today on my own behalf and not as an agent for any other company. I am not on a mission of entrapment or investigation.