Rob’s Intake Form - Rob Nelson

Rob's Online Intake Form

Clicking 'send' will take you to Rob's scheduler where you can book a session or free 20 minute clarity call

Please take a moment and let Rob know how he might help you.

Name*

First

Last

Email address*

Cell Phone *

Address*

City*

State*

Zip Code*

Country*

Emergency Contact - name and phone number :*

Date of Birth:*

Occupation:*

Relationship Status:*

Do You Have Children?*

Members of Household:*

How did you hear about Rob?*

Issues not mentioned above:

Have you worked with a therapist for any of these issues?*

Have you done EFT before? With a practitioner?*

Are you currently feeling suicidal?*

Do you have a medical or psychiatric condition I should know about?*

Do you have a history or current issues with substance abuse?*

Did you grow up with siblings? What was the birth order?*

Did you have a strong religious upbringing?*

Is there an issue, situation, memory or physical problem you'd like us to start with?*

Optional Questions:

If you were to live your life over, what person or even would you prefer to skip?

What makes you angry and why?

Do any people or situations trigger a disproportionate reaction (anger, fear, sadness, guilt) for you?

What is your biggest regret or sadness?

Who might be upset if you were completely healed?

What strengths or positive qualities are you bringing to our work together?

If our work together was amazingly successful, what will change for you?

Is there anything else you'd like Rob to know?

Informed Consent:

Please type your name or initials in the space provided I, ______________________, understand that Rob Nelson is not a licensed therapist, psychologist or health care practitioner and offers EFT (emotional freedom techniques) and Hacking Reality as a self-help educator and ordained minister only. (Please type your name below)*

I am aware that Rob Nelson does not diagnose or treat illness or disease, and does not prescribe medications. I agree not to discontinue or change any medications I am taking while working with Rob Nelson without consulting my doctor. (Please initial below)*

I understand that EFT and Hacking Reality are considered experimental procedures and are not a substitute for medical, psychological or psychiatric treatment or medications, and that it is recommended that I work with my primary caregiver for any condition I may have (Please initial below)*

I understand that EFT and Hacking Reality procedures may bring unresolved and 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 may require further work to resolve. (Please initial below)*

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

I understand that all information I share with Rob Nelson is confidential and that no information will be released to any third party without my express written consent, with the following exceptions: 1) When there is imminent risk of danger to myself or another person. 2) When there is suspicion that a child, elder or dependent is being sexually or physically abused or is at risk of such abuse. 3) When a valid court order is issued for session records. (Please initial below) *

Optional: I give Rob Nelson permission to describe the details of my sessions to his students for training or supervision purposes only, as long as my personal anonymity is strictly protected (Please initial or type 'no')*

I understand that Rob Nelson has a 24 hour cancellation policy and agree to pay for any booked sessions that have not been canceled 24 hours in advance. (Please initial below)*

I understand that session fees cover time spent with Rob only, with no guarantee of efficacy. I understand that my healing and progress toward my goals are ultimately up to me. I acknowledge Rob offers no refunds for unused sessions after 30 days from purchase, however they may be transferred to a friend or loved one.*

I agree to take complete responsibility for my own comfort, health and well-being while working with Rob Nelson. I agree that typing my name below is the electronic equivalent of my actual signature (Please initial below)*

Client signature and date*

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