Dr. Patricia Carrington

Client Application / Intake Form


Application Form:

You may type directly into this form.


Section1:

Date:
   

Name:

Street Address:

City:

State or Province:

Postal Code:

Country:

Home Phone#:

Work Phone #:

Cell Phone #:

E-mail Address:

Date of Birth:

Gender:

Marital Status:

How Did You Hear About Me?:

Occupation:

Below put an X in front of all issues you would like to work on.

 

 Depression or grief

Weight Issues or Self Esteem

Chronic or Current Pain

Stress/Anxiety
Relationship Challenge(s)
Fears or Phobias
Being More Effective at Work or home
I can’t seem to do it  
Balancing Work and Personal Life
Sports Performance (Golf, Tennis, Skiing, etc)
Anger, Frustration, or Resentment
Past Trauma or Painful Memory
Experiencing more joy and/or peace of mind
Other
   

 

1. What issue is troubling you most currently?
 

2. What is the goal you would like to achieve in this program?
 

3.  Briefly describe your life growing up including a bit about your relationship with your parents and siblings.
 

4. Are you an experienced EFT (MTT) user or new to the technique? 

 

5. Have you tried Tapping for the specific issue(s) you would like to address with Dr, Carrington?

 

6. Have you used Tapping successfully for other issues in the past? 

 

7. What, if any, medications are you taking? 

 

8. Are you now, or have you ever considered suicide? (yes or no) If so, when? and why? 

 

9. If you were to let yourself daydream, what is the most meaningful shift you can imagine occurring as a result of your Energy Psychology treatment?  What would you ideally like to see happen?

 

10. Do you or anyone in your family have a history of substance abuse? If yes, please specify:? 

 

11. Do you have any medical condition(s) of which Dr. Carrington need to be aware? 

 

12. How would your life be different if/when we handle all of your issues?

 

13. What would you like to change in your life?

 

14. What are your financial considerations in selecting an energy psychology treatment plan? What would be feasible for you to pay, and for how long a period of time could you manage to do this? Please be as specific as possible.

 

You must read and agree with Dr. Carrington's waiver before she can work with you. Please read it below, and if you agree, type your name into the box and then click the SUBMIT button .

 

When working with Dr. Patricia Carrington, I understand that I will be introduced to modalities called Emotional Freedom Techniques ("EFT"),  Meridian Tapping Techniques (“MTT”), Ask and Receive (“A&R”), Matrix Reimprinting (“MR”) and other energy practices which are techniques referred to as a type of energy therapy.  Due to the experimental nature of EFT, MTT, A&R, MR, and the other techniques presented, I agree to assume and accept full responsibility for any and all risks associated with utilizing these energy practices. The information presented, including introducing EFT or any other technique, is not intended to represent that EFT, MTT, A&R, MR or any other technique used by Dr. Carrington in her sessions with me, is used to diagnose, treat, cure, or prevent any disease or psychological disorder.  EFT, MTT, A&R, MR or any other technique used is not a substitute for medical or psychological treatment.  Any stories or testimonials presented do not constitute a warranty, guarantee, or prediction regarding the outcome of an individual using EFT, MTT, A&R, MR or any other technique demonstrated for any particular issue.  I understand that Patricia Carrington accepts no responsibility or liability whatsoever for the use or misuse of the information or techniques presented, including, but not limited to demonstrations, training, suggestions, sessions, and related activities utilizing such techniques.  I understand Patricia Carrington strongly advises that I seek professional advice as appropriate before making any health decision(s).  If I am on any medications, I understand I am NOT to change any dosages and should consult my physician or the professional who prescribed my medications.

To accept, type your name in the box: 

Once Dr. Carrington reviews your application, she will notify you by email. There may be several days delay as she goes through all the applications but you will hear soon.

If you have any questions about this form, email: treatment@patcarrington.com