ERT Session Intake Form

Date

MonthDayYear
Date
Emotional Reset Therapy (ERT) Client Intake Form
Full Name*

First NameLast Name
E-mail*

Confirmation Emailexample@example.com
Date of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
This is my*
How Did You Find Me?*

Another clientYou're already a clientFacebookInstagramOnline SearchWebsiteOther
Occupation*
Please understand that all information is held in strict confidentiality. It is very important that the client builds a strong sense of trust with the practitioner. If there is anything further you would like to discuss with me before the session or any boundaries that you would like to set to ensure your comfort and relaxation, please bring these issues to my attention.

If a book, article, or any written materials are ever printed including case studies, Robyn Deakin has permission to use information from my sessions, providing the names and personal information are altered sufficiently to provide significant anonymity. Please check box below
Please check one: *

I AgreeI Disagree
1. Have you experienced an emotional (energy) healing before?*

YesNoUnsure
2. Are you under the care of a doctor, psychotherapist or any other health care practitioner?*

YesNo
2.1 If yes, please provide the name(s) and contact number(s)
3. Are you currently taking any medication?*

YesNo
3.1 If yes, please list all medications.
Include prescribed &/or over the counter medications
4. Have you had any illnesses, injuries, traumas or surgeries that may be affecting your life now?*

YesNo
4.1 If yes, please explain.
5. Are you currently experiencing any symptoms such as pain (physical/emotional), anxiety, tension, stress etc?*

YesNo
5.1 If so, explain with the approximate time the symptom(s) have been present.
6. Select any of the following if the above symptom(s) affect your daily life:*

SleepWorkRelationshipsEnergy levelsOther
7. What is your desired outcome/goal for your session(s)?*
8. What are your long term health goals?*
9. Anything else I should know or you would like to share?*
Disclaimer

All sessions will be documented. These sessions are for reference use ONLY, and will only be used as a reference for any articles, printed material, public speaking, or teaching so that Robyn Deakin can make sure the information is accurate. These documents are confidential.

The treatment provided by the emotional energy healing practitioner is of a therapeutic nature only. It is not of a diagnostic or curative approach. The practitioner is not a medically licensed physician and therefore any suggestions and recommendations made by the practitioner are not a substitute for prompt medical attention. Clients should continue to see their health care provider and should not stop prescribed medications.

The practitioner provides no guarantee of the results from a treatment. The practitioner is not responsible for the misuse of suggestions and comments for the relief or lack of relief of symptoms. The practitioner accepts no responsibility for the client once they leave the treatment rooms.

All information provided by the client will be strictly confidential.

Payment and Cancellation Policy

Payment is to be made prior to or at the time of service by cash or credit card. 24 hours notice must be given for any cancellation or changes to sessions. The full cost will be incurred for changes & cancellations on the day of the session. For any session missed or cancelled without a 24-hour prior notification, there will be a $50.00 charge to the client.
Today's Date*

DayMonthYear
Date
Signature*

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