Questionnaire Questionnaire Name* Date of birth* Phone number Email* Date of session* 1. Have you previously had any EFT or Matrix Reimprinting sessions? If so, what is the name of your practitioner (optional) and what was your experience?*2. Are you on any medication for psychosis?* No Yes 3. Have you ever been diagnosed with any psychological / psychiatric conditions?*If yes, please give details below4. Do you have any health conditions (e.g. epilepsy, heart condition, asthma, respiratory conditions, other) and if so, what medications are you on?*5. Are you currently undergoing treatment of any kind?*6. Have you had any recent accidents or trauma of any kind or been hospitalised for any reason? Please give details*7. If you drink alcohol, how many units per day on average? (If you don't drink alcohol, please put 0)*8. Do you take any recreational drugs and if so, what & how often?*9. Are you or could you be pregnant?* 10. What would you like to work on during your session(s)?*I have requested EFT & Matrix Reimprinting therapy* Agree I would like the practitioner to tap on me during the session (applies to face to face sessions only)?*I understand that I can change my mind at any time. Yes No Disclaimer* I understand that EFT and Matrix Reimprinting are not intended to be a substitute for medical, psychological or financial advice, examination, diagnosis or treatment. I agree to seek the advice of a qualified professional regarding any medical condition or financial issue. I accept full responsibility for my health and well-being at all times when working with EFT Matrix Reimprinting. Terms & Conditions* I have read and understood the full Terms & Conditions, which can be found here: https://www.eft-matrix.co.uk/terms-and-conditions/ Signature* Date* EmailThis field is for validation purposes and should be left unchanged. Δ
