Cuantic System Intake Form
Date of birth including year
Address including city and country
Think about your main problem. Is it more physical, emotional or mental? Use the numbers 1, 2 and 3 to indicate which has first, second and third priority.
Explain your main problem:
When did the problem begin?
Is there any other experience that you think perhaps is related to this problem? For example, a separation, death of a loved one, financial issues etc.? If yes, explain and include dates of occurrence.
How do you feel in relation to the problem?
How bad is the problem right now?
How would you like to be feeling instead?
Please say what you have tried already to help yourself with the problem.
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