Emetophobia Client Intake Form
Please complete this form to help me understand your emetophobia symptoms, limitations, history, and treatment goals.
Full Name
*
First Name
Last Name
Please select your time zone to help set up your discovery call & coaching zooms
*
Please Select
Pacific Time (US & Canada)
Mountain Time (US & Canada)
Central Time (US & Canada)
Eastern Time (US & Canada)
Atlantic Time (Canada)
Newfoundland Time
Greenwich Mean Time (GMT/UTC)
Western European Time
Central European Time
Eastern European Time
India Standard Time
China Standard Time
Japan Standard Time
Australian Eastern Time
New Zealand Time
Age: I need to understand which course material and evaluation you need.
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Have you previously received any mental health support, therapy, or treatment for this concern?
Yes
No
Please write below if so:
How long have you had emetophobia, and have you been diagnosed with any other mental health issues like OCD, agoraphobia, eating disorders, depression, etc.?
Have you ever been formally diagnosed with emetophobia?
*
Yes
No
What are your main goals or concerns regarding emetophobia recovery?
Have you previously sought help for emetophobia or related anxiety?
Yes
No
How is emetophobia limiting your life? Are you able to have an occupation, for example? Please provide details about your work or school here.
Do you have familial or partner support, and do they support you reaching out for help?
Is there anything else you'd like me to know before your Discovery Call?
Submit
Should be Empty: