Phobia Intake Form — Susie Munns

Name

First Name

Last Name

Scale

On a scale of 1-10, with 1 being no fear and 10 being extreme fear, how would you rate your fear of needles?

Events

Can you describe any specific incidents or experiences that have contributed to your needle phobia?

Limiting Beliefs

Are there any specific thoughts or beliefs that come up when you think about needles?

Other Aspects

Are there any other fears or anxieties that are related to or connected with your fear of needles?

Physical Symptoms

Do you have any physical symptoms (such as increased heart rate, sweating, or feeling faint) when you encounter needles?

Other Therapies

Have you ever tried any other methods or therapies to address your needle phobia? If yes, please provide details.

Goals

Are there any specific goals or outcomes you would like to achieve through this EFT session for your needle phobia?

Thank you for completing the needle phobia intake form.

I look forward to working with you, and helping you overcome this fear.

Very best wishes,

Susie x