Help me know you better
Please take your time to fill up this questionnaire to the best of your ability. Please remember there are no right or wrong answers. In this form of healing the best practice is "First Answer that comes to your mind is the best answer". Please go with your intuition rather than over thinking the situation. Please feel free to email me if you feel stuck anywhere.
Sign in to Google to save your progress. Learn more
Email *
Full Name *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Current Country of Residence *
Please specify your Time Zone *
Mobile/WhatsApp Number (include International codes) *
Preferred day(s) of the week
Monday (9.30pm AEST)
Tuesday (9.30pm AEST)
Wednesday (9.30pm AEST)
Thursday (10am AEST to 4pm AEST/9.30pm AEST)
Friday (10am AEST to 4pm AEST/9.30pm AEST)
Saturday (Limited appointment available)
Row 1
Gender *
Issues, Goals and Pain Evaluations
Do your best to answer the following questions as accurately possible , choosing the most problematic issues and rating them from 1 to 10, based on your average daily, weekly or monthly experience. A one is Mild and a ten is most severe. Using this pain scale can help us to identify the severity of the issue(s).
Universal Pain Assessment Tool
Describe your 1st concern (Please give details of any Health, Mental, Emotional conditions that you may be diagnosed or suffering from) *
How painful, problematic or difficult is this issue (1-10)?                                            Please rate your response from 1 being the Mild to 10 Most severe? *
Captionless Image
Mild
Most Severe
How long has it being going on? *
Describe your 2nd concern (Please give details of any Health, Mental, Emotional conditions that you may be diagnosed or suffering from)
How painful, problematic or difficult is this issue (1-10)?                                            Please rate your response from 1 being the Mild to 10 Most severe?
Captionless Image
Mild
Most Severe
Clear selection
How long has it being going on?
Describe your 3rd concern (Please give details of any Health, Mental, Emotional conditions that you may be diagnosed or suffering from)
How painful, problematic or difficult is this issue (1-10)?                                            Please rate your response from 1 being the Mild to 10 Most severe?
Captionless Image
Mild
Most Severe
Clear selection
How long has it being going on?
History Evaluation
This section is designed to gather information about experiences with these issues in the past, which can bring to light important issues to focus on for an ultimate healing process.
Please describe your family situation while growing up as it relates to these issues: *
What(if anything) triggered the onset of this problem? *
Are there any traumas you feel may be related to any of these issues, even indirectly? *
Please list any family members or partners who have or have had similar issues: *
Please describe anything else that may be pertinent or useful to know: *
Are you on any prescription or Over the counter medications? *
Do you take any Ayurvedic, homeopathy or herbal supplements? *
Have you had any previous experiences with any form of Energy Healing? If yes please specify the modality name and year when it was done and how long did you do it. *
Goals and Visualizations
This section is to help you create the vibration of the reality you want, which enables your subconscious computer to look for conflicts. This makes doing work with The Emotion Code easier and more targeted, which can help you to achieve your goals faster!
If you suddenly felt the perfect amount of energy and had no pain of any kind, what would you be able to do?
If you felt really good all the time, how would you help the world?
What would your average day look like if you never had to worry about these issues again?
If these issues went away tomorrow, how would you feel?(focus on each issue at a time if you think it may be helpful)
Load up on these positive feelings and get excited about future! What do you feel now?
Disclaimer
By ticking the checkbox you agree you have read and accept the terms of the disclaimer. *
Column 1
I have read the terms of Disclaimer
I accept the terms of the Disclaimer
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy