New client Intake formPlease fill out the intake form below prior to our first visit. Name * First Name Last Name Email * When is your birthday? * MM DD YYYY What is your address? * Address 1 Address 2 City State/Province Zip/Postal Code Country What is your phone number? * Country (###) ### #### May I add you to my newsletter? * Yes No Whom may I thank for referring you? * Have you experienced Healing Touch, EFT, Emotion Code or other energy therapy before? * Yes No Living situation: Married / Partner / Single * Married Partner Single Number of Children? * Occupation? * Are you under the care of a doctor, psychotherapist, counselor or other health care practitioner at this time? * Yes No If so, please list name(s) and phone number(s). * Are you currently taking any medications? * Yes No If yes, what? * Have you had any illnesses, injuries, trauma, or surgeries that may be affecting your health now? If yes, please explain. * Are you currently experiencing any symptoms (pain, tension, anxiety, etc)? If yes, please explain. * How does this affect your daily activities (sleep, exercise, decision-making, relationships)? * Please indicate which of the following symptoms/concerns are areas of distress in your life: * Depression Mood Swings Anger Alcohol/Drug Use Sleep Problems Anxiety Panic Attacks Memory Problems Eating Problems Hormonal Inbalances Stress at Home Stress at Work Please list any allergies * Religious or Spiritual practice: * What is your desired outcome for today's session? * What are your long-term health goals? * In case of emergency, I authorize Megan Buer to contact the following person/s (please include their name and contact phone number). * Thank you!