Dr. Carrington’s Client Application/Intake Form


* Required


* Name:

* Street Address:

* City:

* State or Province

* Postal Code:

* Country:

* Home or Cell Phone:

Work Phone:

* Email:

* Age Approx:

* Gender

* Marital Status:

* How did you hear about me?

* Your Occupation:

* Choose Your Counseling Package

Enter Coupon Code (if applicable)

* Below, click to check mark all areas of your life you would like to improve / goals you would like to achieve in your sessions with Dr. Carrington.

* 1. What personal issue is troubling you most currently?

* 2. Ideally, what is the goal you would like to achieve in this session with Dr. Carrington?

* 3. Briefly describe your life growing up including a bit about your relationship with your parents and siblings.

* 4. Have you taken a workshop with Gil Alan or experienced an individual session with him?


* 5. Are you an experienced EFT (Tapping) user or are you new to or unfamiliar with the technique?

* 6. Have you ever used the Radomski-Altaffer "Ask and Receive" technique?

* 7. Do you believe in a Higher Power (God, the Universe, Source Energy, etc.)?

* 8. Have you had any paranormal (i.e. out of the ordinary) experiences? If so, describe:

* 9. Do you believe in the concept of “past lives”? (Not required in order to work with Dr. Carrington).

* 10. Do you believe that people can contact deceased loved ones? (Not required in order to work with Dr. Carrington).

* 11. Have you ever considered suicide? (yes or no) If so, when? and why?

* 12. Do you or anyone in your family have a history of substance abuse? If yes, please specify.

* 13. Do you have any medical condition(s) of which Dr. Carrington needs to be aware if planning for your session?

* 14. If you were to let yourself daydream, what is the most meaningful shift you can imagine occurring as a result of your appointments with Dr. Carrington? i.e. What would you ideally like to see happen?

* You must read and agree with Dr. Carrington's waiver before she can work with you. Please read it (see below). If you agree, type your name into the box and click the SUBMIT button.

When working with Dr. Patricia Carrington, I understand that I may be introduced to modalities called Emotional Freedom Techniques ("EFT"), Ask and Receive (“A&R”), Matrix Reimprinting (“MR”) and other practices which are techniques referred to as a type of energy therapy. Due to the experimental nature of EFT, A&R, MR, and the other techniques which may be presented, I agree to assume and accept full responsibility for any and all risks associated with utilizing these energy practices. The information presented by Dr. Carrington, is not intended to represent that EFT, A&R, MR or any other technique used by Dr. Carrington in her sessions with me, is being used to diagnose, treat, cure, or prevent any disease or psychological disorder or that it is being used as a substitute for medical or psychological treatment. Any stories or testimonials presented do not constitute a warranty, guarantee, or prediction regarding the outcome of an individual using EFT, A&R, MR or any other technique demonstrated by Dr. Carrington for any particular issue. I understand that Dr. Patricia Carrington accepts no responsibility or liability whatsoever for the use or misuse of the information or techniques presented, including, but not limited to demonstrations, training, suggestions, sessions, and related activities utilizing such techniques. I understand Patricia Carrington strongly advises that I seek professional advice as appropriate before making any health decision(s). If I am on any medications, I understand I am NOT to change any dosages without their consent and should consult my physician or the professional who prescribed my medications for advice with respect to same.

To accept, type your name in the box:

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