Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

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What do you love about your life right now?

What’s not so great about your life right now?

What's your greatest challenge right now? Think about your family, children, relationships, health, career, inner fulfilment + joy?

What’s missing from your life right now? * Is there anything that calls to you? Something that you long for?

Do you experience feelings of stress, overwhelm or anxiety?

Yes - a few times a month or less

Yes - more than once a week

Yes - several times a week or daily

Can you identify any of the triggers? Write anything you know to trigger feelings of anxiety, overwhelm or stress or simply write, I don't know or N/A

Do you experience any physical pain, illness or disease at the moment?

Please list any ailments you're currently dealing with

If yes, list where and what you believe the cause to be.

Have you experienced any trauma (big or little) in your life? If you feel open to sharing, please list below:

This can include 'big traumas' like a parental disapproval or loss, death of someone close to you, a big accident or frequent hospitalisation, bullying, sexual or physical abuse etc.. It can also including 'small traumas' such as not being picked for a sports team at school, being told your school work wasn't good enough, a partner cheating on you or dumping you, being told to be quiet and not having a right to speak up, being a 'shy' child, not having enough food for a packed lunch at school etc

Are you currently seeking support from other health practitioners (doctor, psychologist, chiropractor, psychiatrist etc) or body workers/healers (EFT, NET, Kinesiology, Energy Workers, Reiki etc)? Please list what profession they are below:

Have you ever tried EFT, meditation, breathwork or other healing modalities before?

Yes

If yes, please list or explain what you've done and your experience

What do you hope to get out of our time together?

Is there anything else you want to tell me?

Please note energy healing and EFT sessions can evoke emotion. It is possible to experience lethargy and low mood/energy following these sessions. It is highly recommended that you don't rush off to other appointments following your session, but allow time to integrate and process whatever surfaces in your session with grounding practices such as journaling, gentle stretches, yoga nidra, rest and nourishing food/water. It is also possible that when a healing of an old pattern/trauma/memory takes place physical symptoms can occur such as pain, skin breakouts, cold/flu like symptoms, headaches, etc. This is a part of the purging process of the memory from the body. You can connect with me at tanya@tanyasavva.com if you have questions about anything that arises in the body. Be gentle with yourself through this process.