Appointment Form and Confirmation | Transformational Tapping with Shannon Buck

Some personal information is requested before for your session

Additional information needed prior to your session. If this information has not been received 24 hours prior to the first session the session will be rescheduled

Use of your information:

We will not, in any circumstances, share your personal information with other individuals or organizations without your permission, including public organizations, corporations or individuals, except when applicable by law. We do not sell, communicate or divulge your information to any mailing lists.

The only exception is if the law or a court order compels us to. We will share your information with government agencies if they need or request it.

Name *

Phone *

Date of Birth *

Email *

Address *

Apt, suite, etc.

Country

City

State

Zip code

Summary of the issue you want to resolve *

Have you received or are you receiving therapy for this issue? *

YES

If yes, does your therapist know you are seeking assistance from an EFT life coach?

YES

Are you presently taking any prescription medication for emotional regulation or sleep? For example…Klonopine for anxiety, Zoloft for depression, ambiene for sleep. *

YES

If yes please list your medications and the dosage.

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