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Consultation Questionnaire

Please note that all fields followed by an asterisk must be filled in.
PDF Version of form

First Name*
Last Name*
E-mail Address*
Home Phone*
Birth Date
Educational Background
Relationship Status
In a Relationship
Health Problems?
Addictions / Habits / Cravings? Please describe:
Are you familiar with EFT?
List the top 4 areas of your life you are A) Unhappy with, then B) Explain how you would like them to be, and C) List any ideas about what holds you back from achieving your desired outcome.
1A - Unhappy With:
1B - How you wish this could be different:
1C - Why you believe you can't achieve B:
2A - Unhappy With:
2B - Wish to change:
2C - Why you can't change:
3A - Unhappy with:
3B - Wish to change:
3C - Why I feel this can't change:
4A - Unhappy with:
4B - Desired change:
4C - Why I feel I can't change things:
Are there more things you're unhappy with?

Please enter the word that you see below.


* If you prefer to complete this form off-line and print and fax, click here for the PDF version of the form.