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Client Intake Form - First Impression

Thank you

Check off the negative emotions that most describe how you FEEL 

Start

Question 1 of 6

" Biggest problem you have in your life right now... When you think about it how does it make you FEEL?" 

 

(Select all that apply)
A

Hurt

B

Sad / Grief / Sadness

C

Betrayed

D

Angry/ anger/ angry at yourself

E

Worthless/ Not good enough

F

Guilt/ Guilty/ feel like a bad person

G

Stupid/ Dumb/ Idiot/ Pathetic

H

Embarrassed

I

Ashamed

J

Bitter

K

Alone/ lonely

L

Invisible/ Small

M

Other

Question 2 of 6

Create an additional list of negative emotions you would like to work on 

Question 3 of 6

"Are you Making picture of the future going wrong? When you see those pictures you are afraid of ... what ?"

(Select all that apply)
A

Fear of being centered out?

B

Fear of being/ getting hurt ?

C

Fear of being/ getting betrayed

D

Fear of failure/ failing ?

E

Fear of letting go ?

F

Fear of being / getting embarrassed ?

G

Fear of screwing up ? Making a mistake ?

H

Fear of looking stupid/ dumb/ incompetent ?

I

Fear of being a fraud ?

J

Fear of being lied to ?

K

Other

Question 4 of 6

Create an additional list of fears you would like to work on 

Question 5 of 6

I Agree:

(Select all that apply)
A

Legal Agreement Welcome to the F.I.X. Code private session. All rights of the F.I.X. Code Technique, branding, licensing, and properties belong to Daniel E. Flear and Ancient Gene Technologies Inc.  Any attempt to copy, rebrand, record, rename or teach in any form the F.I.X. Code without written permission or certified practitioner status from Daniel E. Flear and Ancient Gene Technologies Inc. will result in an immediate fine and Fee of $300,000.00 U.S. payable immediately to Ancient Gene Technologies Inc. You have agreed to have a private F.I.X. Code Session with integrity and respect and to follow the code and conduct of the F.I.X. Code. It is understood that any violation of this agreement in any form constitutes a breach of this agreement and is subject to all legal liabilities and fees that are fully in control of Daniel E. Flear and Ancient Gene Technologies Inc. We thank you for your signed Agreement upon booking your appointment. Your reading and agreeing to this agreement indicates your understanding of our policies and procedures and Code of Conduct as a F.I.X. Code client Thank you  

What to expect in and after a session

In a session :

By phone or in person,

have your list ready.

          Relax and know you are in good hands. 

       No content is required so you don't have to reveal any details. 

All sessions are confidential. 

After your session:

You may experience 'Blow outs'.

Expect to feel blank or not able to find old memories.

You may feel agitated and irritable for a short period of time ( the afternoon for example). 

You may want to speak freely and get everything off your chest... Suggestion is to stay low key after a session so as not to regret your actions. This will pass. Those things that had been triggers for you, will not seem important any longer.

Much has changed and how you feel about things has also changed. 

You may also experience some physical blow outs such as a cleanse in whatever form that may take.

Be gentle with yourself. 

        

 

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