EPT Intake Form
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Name of Client *
Name of Legal Guardian (if the client is under 18 years of age)
Address *
Client Date Of Birth *
MM
/
DD
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YYYY
Phone *
Email *
Marital Status *
In Case Of Emergency: Name & Phone Number *
Where did you hear about Open Heart Holistic Therapy and EPT? *
Do you prefer in-person or video chat for your appointments? *
Does the client have a pacemaker, or internal metal, or pumps? *
List and medications, supplements and/or vitamins... *
Please list any physical issues or symptoms the client is experiencing (whether or not they relate to the current issue): *
What is the reason for your appointment? *
How long have you experienced the current issue? *
Do you know the cause of your current issue? *
Have you sought professional assistance with this issue before? *
What type of traditional or non-traditional therapy have you experienced (examples include: acupuncture, massage therapy, EMDR, NET, psychotherapy, medical intervention, talk therapy, etc…: *
Required
Were any of the above affective? Please explain. *
What would you like to achieve with EPT? *
Informed Consent
We appreciate the opportunity to discuss your problems and concerns. We wish to make it clear that our intent is not to diagnose or prescribe, but to offer recommendations and information to help you establish a healthy order in your daily life. If you seek medical advice or treatment for a physical or mental health diagnosis, please consult a medical practitioner, licensed counselor, social worker, or qualified psychologist. If you are seeking ways to take responsibility for your own health, emotions, and overall well being, we are happy to be of assistance. I consent to receiving Emotional Polarity Technique™ at Open Heart Holistic Therapy LLC for myself and/or the identified client(s). (Please type your name in the box below to acknowledge your understanding.) *
I understand the risks of meeting in-person to receive EPT during the global pandemic of COVID-19. I will take precautions to minimize my exposure to COVID-19. I will not hold Open Heart Holistic Therapy LLC liable in case of exposure to COVID-19.  
Confidentiality Disclaimer
At Open Heart Holistic Therapy LLC we strive to keep your sessions and information confidential. However, any online exchange of information via email, text, video, social media, or phone may not be secure. If a known breach occurs, we will let you know about it as soon as possible. *
Required
I give Open Heart Holistic Therapy LLC permission to communicate via email exchange for any updates. I understand the risks of exchanging information online or receiving EPT sessions online, and I will not hold Open Heart Holistic Therapy LLC liable for any lost or stolen information. *
Required
Information Release
If you would like for me to be able to speak to family members, friends, or healthcare providers about your care with EPT™ please provide a list of names, phone numbers, and emails with whom we can exchange information. If not, leave blank.
Cancellation Policy
Payment is due at each session. If a client does not show up or cancels an appointment within 24 hours of the appointment, then they forfeit the time and cost of the appointment. *
Required
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