Sheri Anderson, EFT - Coach
Condidential Client Intake Form
Date: _____________
*NAME:_________________________* HOME #:____________________WORK/CELL#:____________________
ADDRESS:________________________________CITY:__________________ ST:_____ZIP:________________
D.O.B.___/___/___ SEX:___ MARITAL STATUS:_____ SPOUSE or SIG.OTHER:__________________________
*E-MAIL:___________________________________ How did you hear about me?__________________________
OCCUPATION:_____________________________COMPANY:________________________________________
OTHER MEMBERS OF HOUSEHOLD AND AGE______________________________________________________________
_____________________________________________________________________________________________________
*Below, check all issues you would like to work on. – X by the most urgent issues :
__Depression or grief
__Weight Issues or Self Esteem
__Chronic or Current Pain
__Stress/Anxiety
__Relationship Challenge(s)
__Fears or Phobias
__Being More Effective at Work (or home)
__Balancing Work and Personal Life
__Sports Performance (Golf, Tennis, Skiing, etc)
__Fear of Public Speaking
__Anger, Frustration, or Resentment
__Past Trauma or Painful Memory
__Experiencing more joy and/or peace of mind
__Other________________________________________________
Have you seen a therapist for these or any other issues, and if so, when?
_______________________________________________________
What, if any, Medications are you taking?
________________________________________________________
Intake Questions: Please tell me everything you think I should know about the issue you want to work on first (write as much as you can think of-the more information you give me ahead of time, the better). For instance:
Physical complaint or issue. ____________________________________
What is the function, body process or life process does this part of the body have?
What does it feel like?
When do you feel it?
Where do you feel this? (be specific about location of pain)
If a injury - how did it happen?
When was the first time you noticed the problem & how does it affect your life?
What do you think is the cause of it?
What do other (doctors, friends, family, etc.) think is the cause of it?
How long have you had this problem?
What was going on in your life when you felt this? (very important - stress/trauma/other)
What do you think about it?
What do you tell yourself about it? (faults beliefs)
How do you feel about this pain & body part? (be specific as this may bring up other aspects or issues we need to deal with that are associated with this issue - fears/beliefs)
Go deeper into your feeling & emotions.
If this part of the body or this injury were a metaphor of something what would it be? Use a metaphor to describe what it feels like.
Where in your life have you been reluctant to ________ .
Who do you blame for this problem?
How has this been a pattern in you life?
Why haven’t you let go of this problem? What benefits do you get from holding on to this problem? What are you getting in a positive way from having this problem?
If you changed this part of your life, what new problems might that bring?
Who might be harmed or unhappy if you changed that part of your life?
What would be different/better about your life if you overcame the problem?
If it were a color, what color would it be?
Anything else you can think of regarding it?
Please answer the following thought provoking questions:
If you were to live your life over, what person or event would you prefer to skip?
What are the most traumatic events (emotional or physical) that have happened to you? Identify them in a way that makes sense to you and provide details if you wish.
What makes you angry and why?
What was the last time you cried and why?
What is your biggest regret or sadness?
What is missing in your life to make it perfect?
What do you wish you had never done?
Name 3 fears that you would rather not have.
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