Emetophobia Client Intake Form

Emetophobia Client Intake Form

Please provide some information to help me understand your needs. After submitting, you will be directed to a pre-consultation video where many of your questions will be answered. Pricing may vary depending on age, severity, how payment is paid, and more-which will be finalized on a free discovery call.
Full Name*

First NameLast Name
Email Address: Please provide an accurate email address that will be used to send your emetophobia evaluation report and any related materials if you sign up.*
example@example.com
Age: I need to understand which course material and evaluation you need.
Note: If you require financial support to work with me and are a child, teen, or young adult, kindly inform me if a guardian or parent needs to be present during our discovery call.
Please select your time zone to help set up your discovery call & coaching zooms
Phone Number
Please enter a valid phone number.
Have you ever been formally diagnosed with emetophobia?*

YesNoNot sure
How long have you had emetophobia, and have you been diagnosed with any other mental health issues like OCD, agoraphobia, eating disorders, depression, etc.?
How would you describe the impact of emetophobia on your daily life?*

Mild – Occasional discomfort, rarely affects activitiesModerate – Sometimes affects daily tasks or social lifeSevere – Frequently limits activities and causes distressOther (please specify)
What are your main goals or concerns regarding emetophobia recovery?
Have you previously sought help for emetophobia or related anxiety?

YesNo
Any other details you'd like to share about previous interventions, therapies, or medications:
If you have children, how many do you have, how old are they, and how is the emetophobia affecting your pregnancy or parenting right now?
Do you have familial or partner support, and do they support you reaching out for help?

YesNoNot sure
How is emetophobia limiting your life? Are you able to have an occupation, for example? Please provide details about your work or school here.
Anything else you want to share?
After submitting this form, click the button below to watch the preconsultation video on our blog. [Watch Preconsultation Video
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