Personal Transformation Intake Form

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Please Fill in Questions Below. Note: Some questions are optional. Required information has *

Date *

YYYY

First & Last Name *

Phone Number

Date of Birth

YYYY

Emergency Contact Name & Phone Number *

Address

Relationship Status *

Single

Married

Its complicated

Household Information: Children, family, roommates etc.

Anything else I should know about your household?

Please check all that apply *

Divorce or Break Up

Traumatic Memories

Anxiety or Depression

Weight Issues

Chronic Pain or Illness

Grief

Success Issues

Procrastination

Lack of Joy, Purpose or Creativity

Low Self Esteem

Stress from Natural Disaster or Evacuations

Anger and Resentment

Other:

Required

Any issues not mentioned above?

Any significant injuries or accidents?

Have you worked with a therapist for any above or other issues? *

Do you have previous experience with EFT? Please Describe. *

Do you have a history of: *

Sezures

Panic Attacks

Attempted Suicide

Psychiatric Issues

Severe Depression

None of the above

Other:

Required

Are you currently feeling suicidal? *

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

Do you have history or current substance abuse? Please Describe. *

Did you have a strong religious upbringing? Please describe. *

Optional Questions :The Following Questions are optional, but helpful in allowing us to identify potential blockages ahead of our session so we can spend more of our time tapping together.

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

What makes you angry and why?

When was the last time you cried and why?

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

What is your biggest regret or sadness?

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

Would anyone be upset if you were completely healed?

What are three positive goals you would like to achieve?

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

How would you like to feel at the end of the session?

Is there anything else you’d like me to know?

Informed Consent: Required

I understand that Ariel Rose Pacheco (a.k.a. Ariel Rose) is not a licensed physician, therapist or health care practitioner and that the EFT (Emotional Freedom Technique) and energetic mentoring are alternative or complementary to services offered by the state.

The services provided are a combination of EFT, guided meditation, breath work, prayer work, shamanic technique, quantum mechanics & energy education. I am aware that Ariel is a self-help educator. *(Please type your name below) *

Except in the case of gross negligence or malpractice, I or my representative(s) agree to fully release and hold harmless Ariel Rose Pacheco from and against any and all claims or liability of whatsoever kind or nature arising out of or in connection with my session(s). *(Please Type Initials below) *

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

I understand that EFT & above stated techniques are considered experimental procedures are not a substitute for medical, psychological or psychiatric treatments or medications and it is recommended that I work with my primary care giver for any condition I may have. *(Please initial below) *

I understand that EFT and above practices and technique may bring unresolved and distressing memories and related emotions and physical sensations into my awareness, and that it is possible that disturbing material may continue after session that 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 above techniques can lead to a shift in perspective that might make strongly held beliefs feel less urgent or perhaps even reverse completely. (Please Initial Below) *

I understand that all the information I share with Ariel Rose is confidential and that no information will be release to any third party without my express written consent, with the following exceptions: 1)When there is imminent risk to myself or another person. 2) When there is suspicion that a child or elder 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) *

I understand that Ariel Rose has a 24 hour cancellation policy and I agree to pay for sessions that have not been cancelled 24 hours in advance. *(Please initial below) *

I understand that Sessions are held via Zoom unless otherwise arranged and that it is my responsibility to have adequate technology and privacy for our entire session. *(Please initial below) *

I understand that session fees cover time spent with Ariel only, with no guarantee of efficacy. I understand that my healing and progress towards my goals are ultimately up to me. I acknowledge Ariel offers no refunds, however that unused sessions from packaged may be gifted to a friend or loved one within 90 day of purchase. *(Please initial Below) *

I agree to take full responsibility for my own comfort and well being while working with Ariel Rose. I agree that typing my name below is that electronic equivalent of my actual signature. *(Please initial below) *

Client signature (full name typed) and date *

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