Intake Form

PERSONAL TRANSFORMATION INTAKE FORM

Bryn Lowrie Yahn, M.S., Licensed Psychologist, EFT and Hacking Reality Practitioner
Today's date
Name
Phone Number
Email
Address
City, State, Zip Code
Date of Birth
Occupation
Relationship status
Children (how many and ages)
Other members of household
Emergency Contact name, relationship to you, and phone number
Please let me know how you heard about me
I would like to receive newsletters/communication from Bryn Lowrie Healing
Below, please put an X below all the issues you would like to work on. Please put an XX below the most urgent issues:
Divorce or breaking up
Stress or anxiety
Fears or Phobias
Weight Issues
Depression
Marriage or Relationship Problems
Traumatic Memories
Sexual Problems
Lack of Joy
Workaholic
Procrastination
Chronic Pain
Self Esteem
Grief
Work Performance
Anger, Frustration, Resentment
Prosperity
Lack of Purpose
Issues not mentioned above:
Have you seen a therapist for any of these or other issues? If so, when?
Have you done EFT (Tapping) before? If so, with a practitioner?
Do you have a history of Epilepsy or Seizures?
Do you have a history of panic attacks?
Are you currently feeling suicidal?
Have you ever felt suicidal or made an attempt?
If the above answer was "yes," please elaborate on when and why:
Do you have a history of addictions or substance abuse?
Are you taking any medications? If yes, what medications?
So you have a medical or psychiatric condition I should know about? If yes, please explain.
Did you grow up with siblings? If so, what was your birth order?
Did you have a strong religious upbringing? Did you go to Catholic school?
Any surgeries as a child? If so, please explain.
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 sadness or regret?
If our work together was amazingly successful, what would change for you?
Would anyone be upset if you were completely healed?
What are 3 positive goals you would like to achieve in our sessions together?
What strengths or positive qualities are you bringing to our work together?
How would you like to feel at the end of the session?
Is there anything else you would like me to know?
Payment and Cancellation Policy:

Payment for the session is required at the time of booking and is confirmation for your appointment. Please give at least 24-hours notice if you need to reschedule your appointment. If the cancellation is within 24 hours, you will be charged the full rate of the session. There are no refunds for individual sessions, full packages, or partially used packages.

Payment can be made through Venmo: @Bryn-Yahn, or if you would prefer, let me know and I can send you a PayPal invoice (an additional 3.8% will be added for transaction fees for PayPal).

Sessions are up to 90 minutes long. The current rates are below:

One, 90-minute session: $200

Package of 5, 90-minute sessions: $925

Package of 12, 90-minute sessions: $2040
Confidentiality:

Your sessions with Bryn Lowrie Yahn, M.S., Licensed Psychologist, are private and confidential. Private information can only be released with your written consent. The exceptions to this are mandated by law and include: a) reporting of abuse of children or vulnerable adults, b) a situation where disclosure is necessary to protect you or someone else from imminent and serious harm, c) records subpoenaed by the court.
Email and Text Communication:

Email and text communication are not considered "secure." Email and text communication is used for scheduling and appointment reminder purposes only. Ongoing conversation from the healing sessions will not be continued through email or text exchanges. A healing session is done either by a Zoom/video meeting, or a phone call.
Clients Residing Outside of Minnesota:
Bryn Lowrie Yahn is Licensed as a Psychologist in Minnesota. If you reside outside of Minnesota, Bryn Lowrie Yahn is not working under a license, and the sessions are considered healing sessions and not psychotherapy sessions.
INFORMED/TREATMENT CONSENT
I understand that treatment with Bryn Lowrie Healing is not a substitute for medical, psychiatric, or other forms of treatment. It is recommended that I currently work with my primary care practitioner/doctor for any condition that I may have.

I understand that some techniques, like EFT, may bring unresolved or 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 require further work.

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

I agree to be treated by Bryn Lowrie Yahn. I also understand that Bryn Lowrie Yahn is not an emergency or crisis service. For a crisis situation, I will call 911 or go to the emergency room.

I agree to take complete responsibility for my own comfort, health, and well-being while working with Bryn Lowrie Yahn.

I agree that the electronic signature below is equivalent to my actual signature. By signing below, I agree to all of the statements listed above.
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PERSONAL TRANSFORMATION INTAKE FORM

Below, please put an X below all the issues you would like to work on. Please put an XX below the most urgent issues:

Clients Residing Outside of Minnesota:

INFORMED/TREATMENT CONSENT