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.
How long have you had emetophobia, and have you been diagnosed with any other mental health issues like OCD, agoraphobia, eating disorders, depression, etc.?
What types of therapies, medications, or interventions have you tried previously, and how would you describe your experience with them?
What are your main goals or concerns regarding recovery? Who would you be without Emetophobia?
How is emetophobia limiting your life? Are you able to have an occupation, for example? Please provide details about your work, social life, or school here.
Do you have familial or partner support, and do they support you reaching out for help?
If you rely on financial support and would like me to discuss the details of working together with a parent, please provide their contact information.
Is there anything else you'd like me to know before your Discovery Call?
Submit
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