Last Name, First Name *

Telephone *

Email Address *

Birthdate *

Address, City, State, Zip *

Self-Confidence/Esteem *

Overall Stress level *

Energy Level *

Rest/Sleeping Habits *

Exercise Habits *

Eating Habits *

Overall satisfaction of health *

Quality of family relationship *

Quality of friendships *

Quality of business relationship *

Ability to communicate effectively *

Ability to have fun - laughter/humor *

Hobbies/Recreational activities *

Adventure/Travel/Vacations *

Consistent self-care routine *

Overall balance/harmony in life *

Describe any current addictions, including food, alcohol and cigarettes *

Describe your parents' relationship (past & present). Any other significant care givers? *

What did you not like about your mother, father, caregivers? *

Describe your infancy and childhood *

List age and details of childhood injuries, surgeries, illness, accidents and/or emotionally traumatic events *

List any recent injuries, surgeries, illnesses, accidents and/or emotionally traumatic events *

Describe current/most primary relationship. Married or have you been married? Children (ages, gender of each)? *

Discuss significant attitudes about sex. How do you feel about your sexuality? *

Describe any current/recent emotional challenges *

List any forms of past/present therapy. Describe any prior emotional process work. *

What is your most negative thought about yourself/life? *

What is your most negative thought about relationships? *

What is the emotion that is easiest for you to express? *

What is the emotion that is the most difficult for you to express? *

What are your major fears? How do you deal with fear? *

What are the things/person/situation that angers you the most? How do you deal with anger? *

Briefly describe any spiritual or religious beliefs. *

What would you like to accomplish with this work? *

Do you have any of the following conditions? If checked, please explain below as clearly as possible *

List any medications you are currently taking *

If you were hospitalized in the last 3 years, please explain the reason *

Are you under the care of a psychotherapist *

If yes, please provide their name and phone number

Emergency contact name & telephone number *

I understand the nature of the body-mind process and realize it is not psychotherapy or a substitute for psychotherapy. I take full responsibility for consultation with a medical doctor or therapist regarding any concerns about my participation. I agree to hold Emperador Enterprises/Sol Discovery/Jennifer Emperador not liable for any complications resulting from this work. I agree to participate with Emperador Enterprises/Sol Discovery/Jennifer Emperador in the process of my healing journey with the acknowledgement of my NAME & TODAY'S DATE below. *

Disclaimer: Emperador Enterprises/Sol Discovery does not provide medical diagnosis or consultations related to health, medical or psychiatric issues; nor does it serve as substitute for medical or psychological diagnosis and treatment. It is recommended you see a licensed physician or licensed healthcare professional for any physical or psychological ailments you may have. By utilizing the services and information provided by Emperador Enterprises/Sol Discovery, you acknowledge and agree to fully release, indemnify, and hold harmless, Emperador Enterprises/Sol Discovery and others associated with Emperador Enterprises/Sol Discovery, from any claim or liability whatsoever, including without limitation, direct or indirect, special incidental, compensatory, exemplary or consequential damages, losses or expenses. Any information, stories, examples or testimonials presented on the Sol Discovery website does not constitute a warranty, guarantee, or predication regarding the outcome of a treatment with Emperador Enterprises/Sol Discovery. You may not disseminate, modify, copy, in whole or in part, such copyrighted material unless specifically or permitted to do so by Jennifer Emperador (Emperador Enterprises/Sol Discovery). By continuing to explore this website, or choosing to respond with and receive any coaching, breath work or energy sessions from Emperador Enterprises/Sol Discover, you agree to all of the above. *