Print Name

Date

Date of Birth

Age

Gender

—Please choose an option—MaleFemale

Contact Number

Email Address

Residential Address

Emergency Contact Name and Relationship:

Number of Children:

Relationship Status:

Occupation:

Employer:

Primary Care Physician/Health Care Provider Name and Contact Number:

Is there anyone else in your support network whom you would like me to have access to in times of need? Please write their Name, Email and Contact Number:

Minors, 19 Years of Age and Under:
I declare that I am the Parent or Legal Guardian of (Client), please print their name and age below:

I authorize my child or minor to participate in Energy Psychology (EP), Emotional Freedom Technique (EFT or Tapping), Quantum Emotional Freedom Technique (QEFT) Qigong and Meditation sessions with Our Eudaemonia, Gurvinder Dhol. In the interest of my child or minor gaining the most benefit, I waive my right to their information so they can develop a trusting relationship with Our Eudaemonia, Gurvinder Dhol. I understand that I can still gain general feedback under these conditions.

Medical History Part 1

Have you been diagnosed with depression, anxiety, addiction, bipolar disorder, manic depression, mood disorder, impulse control issues, or any emotional or behavioural difficulties? If yes, please specify with dates and details of any diagnosis, as well as physician(s) or practitioner(s) and who made the diagnosis.

Have you participated in any counseling, therapy, or recovery programs? If so, please provide details about the program, including dates, and describe your experience with it. Additionally, specify the treating physician(s) or practitioner(s) involved and whether you found it objective or not.

Have you ever used or been prescribed medications for conditions such as depression, anxiety, addiction, bipolar disorder, manic depression, mood disorder, impulse control issues, or other emotional or behavioral difficulties? If yes, please list the medications prescribed or used, including dosages, the physician or practitioner who prescribed them, and share your experience with the eƀectiveness o these medications.

Have you ever experienced thoughts of suicide, been diagnosed as suicidal, or attempted suicide? If yes, please provide details, including any thoughts or fantasies you may have had about suicide.

Have you ever experienced feelings of being a danger to yourself or others, either currently or in the past? If yes, please provide details about these experiences.

IF YOU FEEL SUICIDAL, OR OTHERWISE DANGEROUS TO YOURSELF OR OTHERS, IMMEDIATELY CONTACT A QUALIFIED MENTAL HEALTH PROFESSIONAL FOR EVAULATION AND TREATMENT.

Medical History Part 2

Are you presently using any medications not mentioned earlier? If so, kindly provide details on the medication, its purpose, dosage, duration of use, and the healthcare professional who prescribed it.

Please check if you have ever been treated for:

High Blood Pressure	Type 2 Diabetes	Epilepsy/Seizures
Chronic Pain	Post-Traumatic Stress Disorder	Neck, Head, or Eye Pain

If you have checked any of these conditions, please provide details such as dates of treatment and the name of your treating physician or practitioner:

IMPORTANT: CLIENTS WITH A HISTORY OF EPILEPSY OR PSYCHOTIC EPISODES SHOULD ONLY HAVE TAPPING SESSIONS UNDER DIRECT SUPERVISION OF A PHYSICIAN OR THERAPIST.

IMPORTANT: IF YOU HAVE CHECKED PTSD, PLEASE REMEMBER THAT OUR EUDAEMONIA, GURVINDER DHOL DOES NOT PROVIDE MEDICAL TREATMENT, PSYCHOTHERAPY, OR ANY TYPE OF MENTAL HEALTH COUNSELING. IF YOU DESIRE SUCH SERVICES, BUT ARE STILL INTERESTED IN TAPPING, I WILL GLADLY REFER YOU TO A MENTAL HEALTH PRACTITIONER WHO USES TAPPING.

Have you experienced a prolonged illness? If yes, please provide a detailed description.

Have you been diagnosed with any autoimmune disorders? If yes, please specify:

Can you describe your typical sleep patterns? This includes your regular bedtime, the duration of your sleep, and the quality of your sleep.

Do you experience significant consistent physical pain? If yes, please specify the location(s) on your body, when the pain started, its history, and any treatments you've undergone.

Do you currently experience any physical discomfort or limitations? For instance, are you feeling discomfort in your elbow or any other part of your body? If so, please specify the areas affected.

Do you experience any discomfort, pain, or strain when rotating your eyes? If so, does it impact your head, neck or shoulders? Our Eudaemonia, Gurvinder Dhol incorporates a version of EMDR (Eye Movement Desensitization and Reprocessing) during sessions. Please indicate any concerns or issues related to eye strain or eye health.

Getting to Know You

Are you familiar with or have you ever used Tapping? If yes, could you please describe your understanding or experience with it?

Have you previously practiced Tapping? If so, please specify the timeframe when you used it, identify the practitioner(s) you collaborated with, and elaborate on your experience as well as any observed outcomes.

Could you elaborate on the specific reasons that led you to seek assistance from Our Eudaemonia and your interest in Tapping?

Have there been any notable life events, including those from childhood? If so, please list them along with approximate dates.

Could you please provide a brief overview of the challenges or difficulties you've faced leading up to seeking assistance from Our Eudaemonia? This will help me better understand your situation and how Our Eudaemonia can support you.

Apart from the methods mentioned earlier, have you tried any other approaches to address these concerns? If so, could you please provide more information about those attempts.

Please check any of the following that apply to you:

Headache	Inferior Feelings	Shy With People	Can’t Make Friends
Dizziness	Feel Tense	Home Condition Bad	Afraid Of People
Fainting Spells	Feel Panicky	Obsessions	Unable To Enjoy Things
No Appetite	Fears and Phobias	Depressed	Always Worrying
Over Eating	Suicidal Ideas	Take Tranquilizers	Don’t Like Weekends Or Vacations
Stomach Trouble	Alcoholism	Dangerous Drugs	Can’t Make Decisions
Bowel Disturbances	Allergies	Gambling	Always Tired
Unable to Relax	Always Sleepy	Financial Problems	Over Ambitious
Recurrent Dreams	Can’t Keep A Job	Hallucinations	Insomnia
Don’t Stand Up For Yourself	Sexual Problems	Feel Unsafe	Prefer To be Alone

If the issues or obstacles that led you to Our Eudaemonia were no longer present in your life, do you believe your life would improve or change in any significant way?

Please outline the top three objectives or aspirations you aim to achieve through Our Eudaemonia's services:

Do you have a belief in a Higher Power? If so, what term or name do you use to refer to it? (e.g., God, Universe, Source, Spirit, etc.)

Would you be open to incorporating Quantum Emotional Freedom Technique (QEFT) during our sessions, particularly when patterns emerge? QEFT delves into intergenerational traumas stemming from societal and cultural experiences that may still be ingrained in the body's biology through epigenetics. Would you be willing to explore QEFT as a means of addressing the root causes of your patterns?

Do you incorporate physical activity into your routine? If so, could you describe the activities you participate in to maintain an active lifestyle and how frequently you engage in them each week?

Do you have a meditation practice? If so, how long do you meditate each day, and when did you start integrating meditation into your daily routine?

Is there any other information you'd like to provide or any other aspect of your situation you feel is important to mention?

Confidentiality

I acknowledge that confidentiality is generally maintained, with specific exceptions such as reporting instances of current abuse of a minor, elderly, or disabled person, or threats of serious bodily harm to myself or others. I understand that confidentiality may be legally overridden by a court order requiring Our Eudaemonia, Gurvinder Dhol, to disclose information. If faced with a legal situation involving confidentiality, I have been advised to seek legal counsel.

Confidential Intake Disclaimer

I acknowledge that Our Eudaemonia, Gurvinder Dhol, does not offer medical treatment, psychotherapy, medical diagnoses, or cures for mental health conditions. If I require such services and still wish to explore Tapping, Gurvinder Dhol will guide me to a Mental Health Professional/Counselor utilizing Tapping. Engaging in EP, Tapping, QEFT, Qigong, and Meditation with Our Eudaemonia, Gurvinder Dhol, does not replace mental health treatment or medication, and I must consult a Mental Health Professional/Counselor or Medical Professional before altering any treatment or medication. I recognize that Our Eudaemonia, Gurvinder Dhol, has provided an opportunity to address any queries about this Agreement.

Confidential Intake Waiver

I have thoroughly reviewed this document and affirm the accuracy of all my responses. I understand that I can inquire about any concerns now or later. I willingly agree to engage in Energy Psychology, Tapping, Quantum Emotional Freedom Technique, Qigong, and Meditation services offered by Our Eudaemonia, Gurvinder Dhol, as delineated in this form.

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