Contact Form

Name: *

City: *

State: *

Zip: *

Home Phone: *

Cell Phone: *

Skype: *

Email: *

Emergency contact – name and phone number: *

Occupation: *

Date of birth: *

Relationship Status: *

Children: *

Other Members of Household: *

Please let me know how you heard about me: *

Below, X all the issues you would like to work on. Put an XX by the most urgent issues:

Issues not mentioned above:

Have you seen a therapist for any of these or other issues? *

Have you done EFT before? With a practitioner? *

Do you have a history of:

Epilepsy or Seizures
Panic Attacks
Asthma
Severe Depression

Are you currently feeling suicidal? Have you ever felt suicidal or made an attempt? If so, when? And why? *

Do you have a history of substance abuse? *

Are you taking any medications that may affect you mentally or emotionally? *

Do you have a medical or psychiatric condition I should know about? *

Did you grow up with siblings? What was the birth order? *

Did you have a strong religious upbringing? Catholic school? *

Any surgeries as a child? *

Is there a situation, issue, memory or physical problem you’d like us to start with? *

If you were to live your life over, what person or event would you prefer to skip? *

What makes you angry and why? *

When was the last time you cried and why? *

Do any people or situations trigger a disproportionate reaction (anger, fear, sadness, guilt) for you? *

What is your biggest regret or sadness? *

If our work together was amazingly successful, what would change for you? *

Who would be upset if you were completely healed? *

What are three positive goals you would like to achieve? *

What strengths or positive qualities are you bringing to our work together? *

How would you like to feel at the end of the session? *

Informed Consent Form

I, ____________________________, understand that Clarymond Hardt is not a licensed therapist, psy-chologist or health care practitioner and offers EFT (emotional freedom techniques) and Matrix Reim-printing as a self-help educator only. *

I am aware that Clarymond Hardt does not diagnose illness or disease, and does not prescribe medica-tions. I agree not to discontinue or change any medications I am taking while working with Clarymond Hardt without consulting my doctor. (Please initial) ____ *

I understand that EFT and Matrix Reimprinting are considered experimental procedures and are not a substitute for medical, psychological or psychiatric treatment or medications, and that it is recommended that I currently work with my primary caregiver for any condition I may have. (Please initial) ____ *

I understand that EFT and Matrix Reimprinting procedures may bring unresolved and distressing memo-ries and related emotions and physical sensations into my awareness, and it is possible that disturbing ma-terial may continue to surface after a session and require further work. (Please initial) ____ *

I also understand that previously traumatic memories may lose their emotional charge and this could ad-versely affect my ability to provide convincing legal testimony. (Please initial) ____ *

I understand that all information I share with Clarymond Hardt is confidential and that no information will be released to any third party without my express written consent, with the following exceptions: 1) When there is imminent risk of danger to myself or another person 2) When there is suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse 3) When a valid court order is issued for session records(Please initial) ____ *

I give Clarymond Hardt permission to describe the details of my sessions to her colleagues and mentors for training or supervision purposes only, as long as my personal anonymity is strictly protected. (Please initial) ____ *

I understand that Clarymond Hardt has a 24 hour cancellation policy and agree to pay for any booked ses-sions that have not been canceled 24 hours in advance. (Please initial) ____ *

I agree to take complete responsibility for my own comfort, health and well-being while working with Clarymond Hardt. I agree that typing in my name below is the electronic equivalent of my actual signa-ture. (Please initial) ____ *

Client Signature (typing your name = consent) and Date *

Personal Transformation Intake Form

Clarymond Hardt - EFT and Matrix Reimprinting Practitioner