Work with Larissa Client Intake Form My Client Intake Form is very thorough in nature and saves us time by gathering your information up front so that we can devote that time to your coaching session. This form collects your name, address, phone number, email address and other personal information related to your request for a personal coaching session with Larissa Groeneweg and Embrace Regenesis, LLC. Please click or tap here if you would like to view our Privacy Policy and see how we protect and manage the information you submit. I consent to having Larissa Groeneweg and Embrace Regenesis, LLC collect my personal information via this form. * Yes Full Name * First Name (name by which you would like to be called) * First names don't always make it clear if you're a man or woman, so please let me know if you're Male or Female. * Male Female When were you born? MM/DD/YYYY format please. (This is needed to ensure you are over 18 years of age.) * Your Home Address * Your Home Address Your Home Address Your Home Address City City State/Province State/Province Zip/Postal Zip/Postal Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Email Address * Home Phone Number (XXX-XXX-XXXX format please) * Mobile Phone Number (XXX-XXX-XXXX format please) Please let me know which phone number is preferred for me to leave voicemails (if needed). * Home Phone Mobile Phone What communication method do you prefer to use when we get together for your personal coaching sessions? * In Person Phone Zoom Please briefly describe the main emotional "challenge" or concern you would like to resolve. * How long have you been struggling with this challenge or concern? * Have you worked with another coach or therapist? * Yes No What was lacking (or didn't work) for you with that coach or therapist? Obviously, you may be feeling doubt or concern about trying again. I would, too. On a scale of 0-10, how high is your resistance or fear for starting this work with me? (10 being very high and 0 being no hesitation at all.) 0 1 2 3 4 5 6 7 8 9 10 Don't worry if you rate this at a 10 and are feeling very resistant. Doubt, fear and anger are normal when you've been hurt and disappointed; especially if you trusted someone to help you and they didn't have the skill, the patience and/or the wisdom to do so. This may be where we'll do our best first work -- let's clear out the resentment and disappointment to make way for hope, excitement and certainty! What else have you tried to help you with this challenge? * What do you really, really, really want right NOW? * What do you need first and foremost? * If you could make a wish and the pain/problem/challenge would be replaced with the perfect circumstances and solutions, what would that look, sound and feel like for you right now? * How did you hear about me? * Web Search Facebook Referral Other Who referred you? If you selected Other above, please let me know how you heard about me. Do you know about and/or have you ever experienced Emotional Freedom Techniques (EFT) before? * Yes No Do you know about and/or have you ever experienced The EGO Tamer® (TET) Tapping Technique before? Yes No Don't worry if you're not familiar with EFT. I'll provide you with more information on that. Don't worry if you're not familiar with TET Tapping. I'll provide you with more information on that. What is your experience with EFT and/or TET Tapping? Watched a video on EFT/TET Tapping Participated in an EFT and/or TET Tapping Class Used EFT and/or TET Tapping with another coach/practitioner Other If you selected "Other" above, please give me a brief description of your experience with EFT and Tapping. DISCLAIMER Larissa Groeneweg and Embrace Regenesis, LLC make no claims, implied or otherwise, regarding the success and/or results from the application of The EGO Tamer® Tapping (aka TET Tapping based in EFT Tapping) and/or personal coaching/counseling (hereinafter referred to as “services”) provided through Embrace Regenesis, LLC. These services are considered experimental and although success rates are in the 80%-90% range, they are as yet undocumented therapies. Larissa Groeneweg is NOT a licensed physician, therapist or psychologist. Larissa Groeneweg is operating as a Registered Nurse and holds a certificate as an EFT & TET Tapping Practitioner. The emotional or physical frailty of some people is such that they should not attempt ANY healing procedure without the presence of a LICENSED THERAPIST. This may be 2% - 3% of the population. If you or the minor of whom you have guardianship who is a client of Larissa Groeneweg and Embrace Regenesis, LLC are in this category, YOU or YOUR MINOR CHILD MUST BE ACCOMPANIED BY YOUR MENTAL HEALTH CARE PROVIDER for a tapping session provided by an Embrace Regenesis provider. Under all conditions and in all circumstances, you accept full responsibility for your personal health and safety and/or that of the minor client under your guardianship. Your compliance with all of your current medical treatments, therapies and prescriptions and/or those of the minor client under your guardianship is expected. Embrace Regenesis, LLC, its employees or subsidiaries shall not be liable for any damages or injury arising out of your access to, or inability to access, all services provided. Embrace Regenesis, LLC, its employees and subsidiaries disclaim any and all liability for direct, indirect, incidental, consequential, punitive and special, or other damages, lost opportunities, lost profit or any other loss or damages of any kind to you or your heirs. RELEASE By my signature below, I acknowledge that I understand and agree with the Disclaimer presented above. Also by my signature, I, and my heirs, in consideration of participation in the services provided by Larissa Groeneweg and Embrace Regenesis, LLC, hereby release Larissa Groeneweg, her family, her heirs, and the officers, employees and agents of Larissa Groeneweg and Embrace Regenesis, LLC, from any and all liability for any loss or damage caused, or alleged to have been caused, directly or indirectly, by the services provided and/or the information or ideas contained, suggested or referenced during the course of services provided by Larissa Groeneweg and Embrace Regenesis, LLC. I understand that my participation in the services provided is strictly voluntary at my own risk and I freely choose to participate and/or permit my minor child to participate in TET Tapping services provided by Larissa Groeneweg and Embrace Regenesis, LLC. I understand that Larissa Groeneweg and Embrace Regenesis, LLC, do not provide medical treatments and/or coverage and I verify that I will be responsible for any costs I or my minor child incur, medical or otherwise, directly or indirectly, as a result of my participation. Please indicate that you have read and agree to the Disclaimer and the Release described above by checking the box below and typing your name as your signature in the space provided. * I've read and agree to the terms and conditions in the Disclaimer and Release above. Name/Signature (Please type in your full name as your signature.) * If you are human, leave this field blank.
