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Individual Sessions form – Please call 631.974.4514 to schedule an appointment as technical issues are being resolved.
Schedule Individual Session
Personal Information
First Name:
Last Name:
Address:
City:
State:
Zip:
Email:
Phone:
Let us know where you would like to have your "Tapping" session:
In Person at Your Thriving Rite
In Person at my Home
In Person at my Office / Work
Over Skype
Skype:
When would you like to have a session?
First Preference:
Second Preference:
First Preference Time:
Morning
Afternoon
Evening
Second Preference Time:
Morning
Afternoon
Evening
How would you like to be contacted to confirm your session?
BY PHONE
BY EMAIL
Continue
CLIENT INTAKE FORM
Please tell me in detail why you are here and what you hope to accomplish during your time with me.
What symptoms are you currently experiencing? Please include, physical, emotional, mental and spiritual symptoms.
Have you seen a medical or holistic doctor, or any other practitioner for these symptoms?
Please tell me the results of these visits.
On a scale of 1-10, how happy are you in your life right now?
1
2
3
4
5
6
7
8
9
10
Miserable
Neutral
Extremely Happy
On a scale of 1-10, how severe do you perceive your issue or pain level.
1
2
3
4
5
6
7
8
9
10
Miserable
Neutral
Extremely Happy
Can you determine how long this issue or pain has been a part of your life and when it began? Please be as specific as you can.
How would we know if we have reached successful results?
In addition, do you have any questions or concerns? Please tell me.
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