New Client Form | Effective Trauma Therapy

Name*

Address

Email*

Date of Birth*

Mobile*

Alternative contact number

Confidentiality
All the personal information gathered during the provision of the EFT Session/s will remain confidential.
Fees
The length and type of consultations vary depending on the focus and individual requirements. To discuss the type of session that best suits your individual needs please call Karen. Personal circumstances may be taken into consideration.
Cancellation Policy
If you wish to change or cancel an appointment that you have made, please give as much notice as possible. If you change or cancel an appointment within 2 days, you will be charged half the payable fee. If you change or cancel an appointment with less than 24 hours notice (or if you do not attend a scheduled appointment) you will be charged the full fee.
I have understood the above information and agree to these arrangements for the EFT services provided by Karen Corbett.

What is the issue that you want to resolve?*

Background*

Were there any significant disruptions to your relationship with your parents during childhood? This includes separations, illnesses or accidents.

Other

Please list anything significant that you feel may be relevant to your EFT session.

Parents*

Please tick any of the following that you feel describe your relationship with your parents or primary care giver/s:

Siblings / School*

Please tick any of the following that you feel describe your relationships with other children:

Critical
Safe
Bullying
Nurturing
Abusive
Clear boundaries
Supportive
Other

Have you ever suffered from:

Anxiety
Insomnia
Depression
Psychosis
Have you ever been diagnosed with a mental illness?

Any other comments