top of page

Safe Space Tapping

Home
Book Online
Intake Form
Learn More
Photography
Blog
Gift Card
Contact
More

Use tab to navigate through the menu items.

Contact Me

Reach out anytime with questions by sending an email via the contact form, or calling:

319-361-4071

Or fill out my intake form here:

Note: all of my sessions are done over Zoom, Facetime, or telephone.

First name

Last name

Email*

Phone

Write a message

Yes, please subscribe me to your blog.

Intake Form

If you are ready to begin your journey with me, please fill out the form below.

First name*

Last name*

Email*

Phone*

Multi-line address

Country/Region*

Address*

Address - line 2*

City*

Zip / Postal code*

Emergency Contact (Name & Phone Number)*

Date of Birth*

Month

Day

Year

Occupation*

Relationship Status*

Do you have children?*

Members of Household*

How did you hear about Torri?*

Please check all that apply*

Divorce or Breaking Up

Traumatic Memories

Anxiety or Depression

Weight Issues

Chronic Pain or Illness

Grief

Sexual Problems

Prosperity or Success Issues

Procrastination

Lack of Joy or Purpose

Self Esteem

Anger, Frustration or Bitterness

None of the Above

Other

Have you worked with a therapist for any of these issues?*

Have you done EFT before? With a practitioner?*

Do you have a history of:*

Seizures

Panic Attacks

Attempted Suicide

Psychiatric Issues

Severe Depression

None of the Above

Are you currently feeling suicidal?*

Do you have a medical or psychiatric condition I should know about?*

Do you have a history or current issues with substance abuse?*

Did you grow up with siblings? What was the birth order?*

Did you have a strong religious upbringing?*

Is there an issue, situation, memory or physical problem you'd like us to start with?*

___________________

Optional Questions:

If you were to live your life over, what person or event would you prefer to skip?

What makes you angry and why?

Do any people or situations trigger a disproportionate reaction (anger, fear, sadness, guilt) for you?

What is your biggest regret or sadness?

Who might be upset if you were completely healed?

What strengths or positive qualities are you bringing to our work together?

If our work together was amazingly successful, what will change for you?

Is there anything else you'd like Torri to know?

_____________________

Informed Consent:

I understand that Torri Jenn is not a licensed therapist, psychologist or health care practitioner and offers her services as a self-help educator only. (Please type your name below to acknowledge this statement)*

Torri Jenn does not diagnose or treat illness or disease, and does not prescribe medications. I agree not to discontinue or change any medications I am taking while working with Torri Jenn without consulting my doctor. (Please initial below)*

Torri Jenn's services are not a substitute for medical, psychological or psychiatric treatment or medications, and it is recommended that I work with my primary caregiver for any condition I may have (Please initial below)*

Torri Jenn's services may bring unresolved and distressing memories, emotions and physical sensations into my awareness, and disturbing material may continue to surface after a session. (Please initial below)*

I also understand that previously traumatic memories may lose their emotional charge and this could adversely affect my ability to provide convincing legal testimony. (Please initial below)*

I understand that all information I share with Torri Jenn is confidential and that no information will be released to any third party without my express written consent, with the following exceptions:

1) When there is imminent risk of danger to myself or another person.

2) When there is suspicion that a child, elder or dependent is being sexually or physically abused or is at risk of such abuse.

3) When a valid court order is issued for session records.

(Please initial below to acknowledge the above statement)*

Optional: I give Torri Jenn permission to describe the details of my sessions to her students for training or supervision purposes only, as long as my personal anonymity is strictly protected (Please initial for Yes, or type 'No' to decline)

I understand that Torri Jenn has a 24 hour cancellation policy and agree to pay for any booked sessions that have not been canceled 24 hours in advance. (Please initial below)*

Session fees cover time spent with Torri only. Efficacy is not guaranteed. I understand my healing and progress are ultimately up to me. Package sessions do not expire but are non-refundable 60 days after purchase. (Please initial below)*

I agree to take complete responsibility for my own comfort, health and well-being while working with Torri Jenn. I agree that typing my name below is the electronic equivalent of my actual signature (Please initial below)*

Client signature and date*

Successfully submitting the form will take you to the Services page where you can book a free 20 minute Clarity call or other session.

© 2026 Safe Space Tapping

bottom of page