Personal Transformation Questionnaire

Name*

Email*

Phone*

Address 1:*

Address 2:

Town:*

County:*

Postcode:*

Emergency Contact - Name and Phone Number*

Date of Birth*

Occupation*

Relationship Status*

Children?*

Members of Household?*

Please check any issues that apply*

Issues not mentioned above:*

Have you worked with a therapist for any of these issues?*

Yes
No

If yes, what issues?

Have you done EFT before? With a practitioner?*

Do you have a history of;*

Epilepsy or Seizures
Panic Attacks
Severe Depression
Psychiatric Issues
Attempted Suicide
None of the Above

Are you currently feeling suicidal?*

Yes
No

Do you have a medical or psychiatric condition I should know about?*

Do you have a history or current issues with substance abuse?*

Did you grow up with siblings?*

Yes
No

Did you have a strong religious upbringing?*

Yes
No

What makes you angry and why?*

When was the last time you cried, and why?*

Do any people or situations trigger a disproportionate reaction (anger, fear, sadness, guilt) for you?*

Yes
No

Why?

What is your biggest regret or sadness*

If our work together was amazingly successful, what would change for you?*

Who might be upset if you were completely healed?*

What strengths or positive qualities are you bringing to our work together?*

Is there an issue, situation, memory or physical problem you'd like us to start with?*

Brief outline of the problem

How long have you suffered with this problem (conflict, ailment, disorder)*

What makes it worse?*

If you didn’t have this problem how would your life be different?*

What steps have you already taken to solve the problem, and with what results?*

What stops you from changing?*

What will be different once you have changed?*

How will this change affect your family and friends?*

What are the good things in your life at the moment (including any people that support you or activities that you enjoy)?*

What does this issue remind you of?*

When was the first time you can remember feeling the same kind of feeling?*

Is there a deeper emotion underlying this problem, what might it be?*

If you could live your life over again, what person or event would you prefer to skip?*

What was happening in your life before or during the time of diagnosis, or when you noticed this problem arise?*

Who else in your family has suffered with this?*

What would you be focusing on if you didn’t spend your time worrying about this issue?*

What is the downside of getting rid of this problem?*

What is the upside of holding onto the problem?*

What is your theory about why you haven’t yet?*

Is there anything about the situation that would be helpful for me to know?

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