Wholistik Living Project LLC. Foundational of Wellness Program History Form

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Welcome Beautiful Souls." Learn to rest in that place within you that is your true home."

Please share the information below to aid me to understand you and your needs.Complete the form as carefully as possible . All information is confidential, as explained in my disclosure statement.

In addition, this form will help me understand your history so we can get a comprehensive view
into the blocks that may have been holding you back.

Cyclic nature of life" Creation. Integration.Rebirth"

Full Name *

Birthday *

YYYY

Best email and telephone number to contact you *

Social media profile

1.Why do you feel I am the best person to guide you on your weight-loss journey? *

2.Why are you seeking help now?What is happening or is different? What stressors do you have? What do you hope will be different by seeking help? *

3.Please give me more details about the issue you name above. When did it start? How often does it happen? How does it affect your life? How have you dealth with it so far?

4.Have you ever experienced similar or emotional/mental health symtoms above? if so, what was the experience like? when did it happen? Did you get help?

5.Has anyone in your family ever experienced mental health or substance use issues? If so, who was it? did they seek help? Do you know what it was like for them getting help? What was it life for you?

6.Do you have any current or prior medical condition? if so, what was/is it? Have you seen a doctor or other healthcare professional for it? What recommendations or treatment did you have? Is there any family history of dis-ease(mental/physical)?

7.Are you currently prescribed or taking any medication or natural herbs/vitamins/minerals? If so, please list the name,dosage, how often you take it, and the prescriber for each medication and for what purpose.

8.Do you now,or have ever,used alcohol,tobacco,recreational drugs or prescription medication other than as prescribed? If so, when did you start, how often did/do you use, and how long did this occur? Please list each substance separately.

9.Who is in your family? What is your relationship with them? Please list all individuals you consider to be apart of your family. For those who are not part of your family of orgin(example, ex significant others). please include the duration of your relationship.

10. What social activities and relationships do you engage in? What important social relationships do you have? Do you belong to any social clubs or organizations? How do you like to spend your free time?

11.What spiritual practices and cultural influences are important to you? Do you belong to a religion,faith or spiritual community? What cultural groups do you identify with?How do you celebrate culture and spirituality in your life? Do you practice (Prayer/Mediation) ?

12.What was life like as you were growing up, both at home and in school? Did you meet developmental milestones or experience any delays?What were your friends like when you were younger? What was school like for you? *

13.What signifcant educational and work/volunteer experiences have you had? What is the highest level of education you have completed ? Are you currently employed?if so,where and for how long?what other work and educational experiences have you had(such as stay-at-home parent, baby-sitting or semester aboard)? Are you satisfied with your current education and employment?

14.What strengths and abilities are you bringing to sessions?What needs or preference do you have that will help us to be sucessful? What coping skills have working for you so far? What is important to know that will help make our time more effective for you?

15.What else is important to know about you?

16.What are some weight-loss health goals that you would like to accomplish during our time together? *

17.What type of services have you received before(Mental Therapy, Coaching, Personal Development Workshops etc? *

18.Why do you feel that you are now ready to do this? *

19.What do you feel is currently preventing you from achieving your weight loss health goals? *

20.On a scale from 1 - 5 ( with 1 being the least and 5 being the most COMMITTED), how committed are you to achieve your weight loss goals? *

21.If you answer below 5 on your level of commitment, please explain *

22.Why is healing important for you? *

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