Client Information-Thank You Soul

Client Information

Please fill out this form as best you can so we can provide you with the most relevant service.

First name

Last name

Cell Phone Number

Address

Emergency Contact - name and phone number

Date of Birth:

Occupation:

Relationship Status:

Do You Have Children?

Members of Household:

How did you hear about Grace?

Issues not mentioned above:

Have you worked with a therapist for any of these issues?

Have you done EFT before? With a practitioner?

Are you currently feeling suicidal?

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

Do you have a history or current issues with substance abuse?

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

Did you have a strong religious upbringing?

Is there an issue, situation, memory or physical problem you'd like us to start with?

Optional Questions

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

What makes you angry and why?

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

What is your biggest regret or sadness?

Who might be upset if you were completely healed?

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

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

Is there anything else you'd like Grace to know?

Informed Consent:

Please type your name or initials in the space provided I, ______________________, understand that Grace Robles-Gallardo is not a licensed therapist, psychologist or health care practitioner and offers EFT (emotional freedom techniques) and Hacking Reality as a self-help educator and ordained minister only. (Please type your name below)

Your Signature

I am aware that Grace Robles-Gallardo does not diagnose or treat illness or disease, and does not prescribe medications. I agree not to discontinue or change any medications I am taking while working with Grace Robles-Gallardo without consulting my doctor. (Please initial below)

Your Signature

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

Your Initials

I understand that EFT and Hacking Reality procedures may bring unresolved and distressing memories and related emotions and physical sensations into my awareness, and it is possible that disturbing material may continue to surface after a session and may require further work to resolve. (Please initial below)

Your Initials

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

Your Initials

I understand that all information I share with Grace Robles-Gallardo 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, elder or dependent 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 below)

Your Initials

Optional: I give Grace Robles-Gallardo permission to describe the details of my sessions for training or supervision purposes only, as long as my personal anonymity is strictly protected (Please initial or type 'no')

Your Initials

I understand that Grace Robles-Gallardo has a 24 hour cancellation policy and agree to pay for any booked sessions that have not been canceled 24 hours in advance. (Please initial below)

Your Initials

I agree to take complete responsibility for my own comfort, health and well-being while working with Grace Robles-Gallardo. I agree that typing my name below is the electronic equivalent of my actual signature (Please initial below)

Your Signature and date