New Client Questionnaire
Please fill out the following information, answer the Self-Assessment Questions and press the submit button on page 2.
Name *
Your answer
Address *
Your answer
Phone: *
Your answer
Email: *
Your answer
Website:
Your answer
Occupation: *
Your answer
Birth date: *
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DD
/
YYYY
Birth time: *
Time
:
Birthplace: *
Your answer
Spouse or Partner: (if applicable)
Your answer
Birth date:
MM
/
DD
/
YYYY
Birth time:
Time
:
Birthplace:
Your answer
Number of children and their ages: (if applicable)
Your answer
Self-Assessment Questions
Please describe what it is that gives you the most enjoyment, sense of wellbeing or purpose.
Your answer
Please describe what it is that gives you satisfaction, peace, recognition or success?
Your answer
What area(s) of your life is the most challenging for you? Please explain.
Your answer
Are you currently in therapy? If so, how is it helping you?
Your answer
Are you in a relationship? If so, how long have you been in your current relationship?
Your answer
Do you suffer from anxiety or PTSD?
Your answer
On a scale of 1 to 10, ten being the highest, on what level do you experience anxiety on a regular basis?
Your answer
What do you feel anxious about?
Your answer
What anxiety or PTSD symptoms do you experience?
Your answer
What fears come up for you on a regular basis?
Your answer
Do you take anti-anxiety or anti-depression medication?
Your answer
Do you suffer with any addictions? Please describe.
Your answer
Do you have lingering, unresolved emotional pain from the past? Please describe.
Your answer
Do you feel stuck repeating undesirable habits? Please explain.
Your answer
Are you living out familial or societal conditioning that doesn’t feel like the real you? Please describe.
Your answer
Do you feel you are living your true place and purpose? Please describe.
Your answer
Do you trust the decisions you make? Please explain.
Your answer
How do you feel in your body?
Your answer
Do you have physical problems or limitations? Please describe.
Your answer
Have you done any kind of bodywork: massage, Rolfing, yoga, other body or movement therapies?
Your answer
If so, how did these modalities help you?
Your answer
What is it you truly desire?
Your answer
What is the reason you want what you want?
Your answer
What is it that’s keeping you from having what you want?
Your answer
If you’re not sure, what would you guess is the reason?
Your answer
What will happen if you don’t get what you truly desire?
Your answer
What will happen if nothing changes?
Your answer
How does that feel to you?
Your answer
Do you believe your life would be better if you could resolve the reactive, not useful emotions that are causing you problems and suffering?
Your answer
Do you want to live with a clean emotional landscape?
Your answer
Do you want to know how to make the best decisions for navigating your life?
Your answer
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