Intake Form Open Form Client Intake Form Name * First Name Last Name Email * Phone (###) ### #### Emergency Contact Phone (###) ### #### Please check all of the issues you would like to work on Stress or Anxiety Workaholic Procrastination Divorce or Break Up Chronic Pain Self Esteem Greif Depression Weight Issues Anger, Frustration, Resentment Fears or Phobias Prosperity Marriage Problems Traumatic Memories Sexual Problems Lack of Joy Lack of Purpose Business Performance Issues not mentioned above Is there a situation, issue, memory or physical problem you’d like us to start with? If you were to live your life over, what person or event would you prefer to skip? If our work together was amazingly successful, what would change for you? What are three positive goals you would like to achieve? By Checking the box below you understand and agree to the following * I understand that NG is not a licensed therapist, psychologist or health care practitioner and offers EFT (emotional freedom techniques) and Matrix Reimprinting as a self-help facilitated education and ordained minister only. I am aware that NG does not diagnose illness or disease, and does not prescribe medications. I agree not to discontinue or change any medications I am taking while working with NG without consulting my doctor. I understand that EFT and Matrix Reimprinting are considered experimental procedures and are not a substitute for medical, psychological or psychiatric treatment or medications, and that it is recommended that I currently work with my primary caregiver for any condition I may have. I understand that EFT and Matrix Reimprinting 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 require further work. I also understand that previously traumatic memories may lose their emotional charge and this could adversely affect my ability to provide convincing legal testimony. I understand that all information I share with Natalie Brooke Glanell is confidential and that no information will be released to any third party without my express written consent, with the following exceptions: When there is imminent risk of danger to myself or another person When there is suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse When a valid court order is issued for session records I agree Thank you for completing that and I will see you soon!