Client Intake Form - Your Tapping Journey

First & Last Name

Email *

Full Address (including City, State, Country if applicable)

Cell Phone Number (xxx-xxx-xxxx format)

Alternate Secondary Number (xxx-xxx-xxxx format)

Name of Emergency Contact Person

Emergency Contact Phone Number (xxx-xxx-xxxx format)

Date of Birth (MM/DD/YYYY format)

Marital Status

Occupation

How did you hear about me?

Please check any of the following issues you may be having at this time. (Check any and all that apply.)

Have you seen a therapist or other practitioner for any of the issues you indicated above (or for any other issues)?

If you answered Yes to the question above, when did you see the therapist or practitioner?

Have you ever been diagnosed with a mental health condition or illness?

What, if any, medications are your currently taking for mental health issues? (If none, please enter "None")

Do you have any medical condition(s) of which I need to be aware?

Are you now, or have you ever been, suicidal?

Do you or anyone in your family have a history of substance abuse?

If you answered Yes to the question above, please provide a brief description.

Please give me a brief description of what you would like help with today.

In a nutshell, please describe for me what your spiritual or religious beliefs are.

Are there any other thoughts/comments you'd like to share with me? (If none, please enter "None" in the box below.)

How did you hear about me?

If referral/other, please specify

Name, Website, etc.

I have read and agree to the terms and conditions outlined in the Session & Class Disclaimer. *

Yes, I have.

Session & Class Disclaimer

By purchasing and/or participating in a class or personal session with Ruthi-Cohen-Joyner, DBA Your Tapping Journey, you agree to and understand that each session or class is an educational and informational experience designed to help you (or your child) and that results will vary from person to person.

You further understand and agree that no medical diagnosis, prognosis or treatment is expressed or implied in these personal sessions or classes. You agree to take full responsibility for your health, mental health, and well-being and understand that these sessions or classes are not designed nor intended to replace medical advice or treatment. You acknowledge that alternative or complementary treatments are not a substitute for traditional medical or psychological care and that it is your responsibility to make decisions as to if and when such care is needed for mental or physical conditions. You agree there shall be no liability on the part of Ruthi Cohen-Joyner, or her heirs, should you fail to do so.

Further, you understand that if you participate in a class that is being recorded, the audio and/or video recordings obtained from that class may be used for promotional purposes or educational purposes or shared with others to further learning and you, therefore, consent to be being recorded for educational or promotional purposes. You understand that all recordings from the class are the exclusive rights of Ruthi Cohen-Joyner, and that you are not entitled to compensation or notification of the use of recordings and photographs in which you appear or speak. No personal sessions will be recorded without prior written consent and would only be to share with the client if requested. All personal session remain totally confidential.

Refund Policy

Your Tapping Journey will do everything possible to provide the services that have been agreed upon and paid for. If for any reason, Your Tapping Journey does not provide said services, a full refund will be provided for services not provided. If however the client simply chooses not to follow through with classes or session already paid for, there will be no refund for services.

Cancellation Policy

Please make every effort to keep your appointments as scheduled. Forty-eight-hour notice is expected if an appointment needs to be canceled. As true emergencies do occasionally occur, each situation will be evaluated individually, however, please respect the time that is set aside for you and do your best to keep our appointment. By the way, since the work we do can bring up strong emotions, sometimes part of you really wants to do this work and another part of you is resistant. Please know that relief comes with keeping appointments instead of running away from your ‘stuff’.

Your agreement with the terms of this Session & Class Disclaimer and Informed Consent, cancellation and refund policies, also covers all future participation by you in sessions and/or classes with Ruthi Cohen-Joyner.

Tell me about yourself!

Session & Class Disclaimer