WHAT OTHERS SAY

"My arm felt better that day, immediately, and never went back to the constricted movement or pain.
This is THE simplest most effective method I have ever seen. Hard to believe that the tapping could
actually remove the residual effects of a car accident. Absolutely amazing. (You can quote me! :) I do
believe you have quite the gift of insight which makes the technique all the more effective!"

Colleen, Luminescent Healing, Fredonia, NY

"Dave zeroes in on core issues with a keen eye, a light and graceful touch and a compassionate heart. I am grateful."

P.S., California

This is an exciting new approach to pain management which can give hope to those who have previously given up on the belief that they can live with less pain. Dave is one of the most insightful & trusting professionals I have ever worked with.

B.Hayes, PhD, LCSW

"EFT is a simple, powerful process that can profoundly influence gene activity, health and behavior."

Bruce Lipton, PhD, Author of The Biology of Belief

"I frequently use EFT for my patients with great results."

Eric Robins, MD,

"Nothing in my traditional medical training in Anatomy, Physiology or Pathology even hinted at what I am now witnessing. ... our previous understanding of how our bodies and our minds work is in need of important revisions and re-directed research."

Chuck Gebhardt, MD

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Intake Form

Confidential Client Intake Form

Date: _____________

*NAME:_________________________* HOME #_______________WORK/CELL#:__________________

ADDRESS:________________________________CITY:__________________ ST:_____ZIP:________________

D.O.B.___/___/___ SEX:___ MARITAL STATUS:_____ Spouse/Significant Other:__________________________

*E-MAIL:___________________________________ How did you hear about me?_________________________

OCCUPATION:_____________________________COMPANY:________________________________________

OTHER MEMBERS OF HOUSEHOLD AND AGE______________________________________________________________

_____________________________________________________________________________________________________

*Below, check all issues you would like to work on. – X by the most urgent issues:

__Chronic or Current Pain

__Depression or grief

__Weight Issues or Self Esteem

__Stress/Anxiety

__Relationship Challenge(s)

__Fears or Phobias

__Sports Performance (Golf, Tennis, Skiing, etc)

__Fear of Public Speaking

__Anger, Frustration, or Resentment

__Past Trauma or Painful Memory

__Other________________________________________________

Have you seen a therapist for these or any other issues, and if so, when?_________________________________

What, if any, Medications are you taking?________________________________________________________

Intake Questions:  Please tell me everything you think I should know about the issue you want to work on first.  Write as much as you can think of-the more information you give me ahead of time, the better).  For instance:

Physical complaint or issue. ______________________________________________________________

What does this issue prevent you from doing or enjoying?

What does it feel like?

When do you feel it?

Where do you feel this? (be as specific as possible)

If an injury – when and how did it happen?

When was the first time you noticed the problem?

What do other (doctors, friends, family, etc.) think is the cause of it?

What do you think is the cause of it?

How long have you had this problem?

What else was going on in your life when you when this issue came into being?

What do you think about it?

What do you tell yourself about it?

How do you feel about it?

If this part of the body or this injury were a metaphor of something what would it be? Use a metaphor to describe what it feels like.

Who do you blame for this problem?

Has this been a pattern in your life?

What is the upside, if any, of having this problem?  What are you getting in a positive way from having this problem?

If you changed this part of your life, what new problems might that bring?

Who might be harmed or unhappy if you changed that part of your life?

What would be different/better about your life if you overcame the problem?

Anything else you can think of regarding it?

Please answer the following thought provoking questions:

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

What are the most traumatic events (emotional or physical) that have happened to you?  Identify them in a way that makes sense to you and provide details if you wish.

What makes you angry and why?

What was the last time you cried and why?

What is your biggest regret or sadness?

What is missing in your life to make it perfect?

What do you wish you had never done?

Name 3 fears that you would rather not have.