Confidential Client Intake Form

Name *

First

Last

Email *

Confirm Email

Mobile Number (inc. area code) *

OK to send or leave text or voice mail messages? *

Address *

Date of Birth *

Time of Birth (if known)

Current Age *

Place of Birth

Nationality

Occupation/work you do

Include what's involved if appropriate.

Religious/Spiritual Beliefs

GP contact details *

Include when last visited & why

Blood Type (if known)

Any past or present physical symptoms *

Allergies etc

Any recent treatments? *

Medical & integrated health e.g. massage, aromatherapy, EFT, EMDR, nutrition etc

Medication &/or Supplements *

Any past or present psychological symptoms (self/family): *

Are you smoke free? (If not, how much do you smoke?) *

Alcohol consumption *

Non-prescription drug use? *

Tea, Coffee, Soft Drinks ( + other caffeine type drinks)? *

Use & Consumption

Other fluid intake...? *

Present Family/Living arrangements: *

Relationship History *

Family Origin *

Sexual activity

Sleep patterns *

Any trouble with Police?

Friends & Fun

Exercise *

Life Stresses *

Experiences with Loss/Bereavement/Relationship Breakdown *

Experiences with Trauma *

Accidents, operations, natural disasters etc.

Fears or Phobias *

Any changes, losses or stresses in past 12 months? *

What is the best thing in your life right now? *

What would you like to change in your life? *

How long has this been a part of your life? *

What was happening in your life when this began? *

Miracle Question – how will you know that it’s changed? *

Previous Counselling / Psychotherapy *

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?

What are your expectations of our work together? *

Anything else you feel I should know? *

Have you read & understood the Privacy Policy & T&C's? *

These are all detailed below at the bottom of the page.

Consent Agreement *

Client agrees with the agreement explained below:

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.

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