Smoking & Weight Loss EFT Client Form

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Emotional Freedom Technique

EFT Client Intake Form

Smoking & Weight Loss EFT Client Form

Before Your Appointment

Home Work

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Smoking & Weight Loss EFT Client Form: Smoking & Weight Loss Client Intake Form

In order to help you understand why you smoke/eat and how smoking/eatting effects you, please answer the following questions carefully. Although your initial responses might be yes to all of them, please take the time to consider each question carefully. Your session will be customized to fit your specific needs and we will spend time finding alternatives for each emotional and habitual need.

I smoke/eat: Yes or No

To elevate my mood _____

To feel comforted _____

For companionship _____

To relieve stress, ease tension ____

To give myself a break _____

To relax ______

To punish myself _______

To feel comfortable socially _____

To break boredom ______

To relieve loneliness _____

To soothe frustration ______

To curb my appetite ______

To bribe myself into action _____

To celebrate ______

To rebel, be different ______

To show my independence ______

To irritate someone in my life ______

To stimulate my creativity ______

To focus and concentrate ______

To organize my thoughts ______

I smoke/eat when: Yes or No

I�m angry ______

I want a reward ______

I�m happy ______

I�m unhappy ______

I�m arguing or after a fight ______

I�m feeling insecure ______

I�m nervous ______

I�m afraid ______

I�m feeling left out ______

I�m driving ______

I�m watching TV ______

I�m working ______

I�m drinking alcohol ______

I�m drinking coffee ______

I�m talking on the phone ______

After eating ______

My body wants nicotine ______

I smoke purely out of habit, _____

Have no emotional attachment ____

Meeting the Need While Dismissing the Habit

Think about the above reasons. Each of them has a positive function; that is, it isn�t wrong to be nurtured, to feel less stressed, to feel comfortable in social situations, or to control your weight. What you are accomplishing with smoking/food has value. It�s just that the habit that has been established to meet the need is one that ultimately destroys, rather than supports. You know there is nothing that can be said about the ill effects of smoking/being over weight that you have not already heard more than once. Further, the suggestion that you can meet the same needs while employing a new behavior or a new habit may seem outright preposterous. But it isn�t, if you�re willing to rely on the power of your subconscious. Your subconscious can provide you with specific, constructive alternatives to smoking/overeatting that will be genuinely desirable.

In Addition, please fill out the 1st client intake form.