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Heart & Soul Healing Remote Session Questionnaire |
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Please take time to fill out this questionnaire. SUMMARIZE AND PROVIDE AS BRIEF AN ANSWER AS POSSIBLE to each question. BRIEFLY Include incidents such as: Upon completion of this form, please mail it back to us at Post Office Box 1500, Cleveland, GA. You can also E-Mail (instructions here) your completed questionnaire. Your payment of $175.00 USD can be made by using the DONATE button on the home page. Payment is via PayPal. If you choose to pay by check, please ensure that payment is received prior to the date scheduled for your session. This fee includes the cost of evaluating your intake sheet as well as the one hour phone session. You are responsible for any telephone charges. When we have received these items, we will call you to set up the actual appointment for the phone session. You will be given a specific date and time to call us on our private line, and you may tape the session if you wish. Before your session, please review "Techniques For Being In The Moment - Clearing, Balancing, and Centering".
PAYMENT INFORMATION Please make checks or money orders payable to Clear Light Arts, ADL.
**note: keep all answers within the lines of these 6 pages. Additional pages will incur additional charges for review** Name____________________________________ email: __________________________ Address __________________________________________________________________ City ________________________________________State ______ Zip _______________ Telephone: Day ____________________________ Evening _________________________ Date of Birth ____________________ Place of Birth _______________________________ Occupation ___________________________________ Marital Status _________________ If married now, or in a committed relationship, how long? __________________________________________________________________________ Children: names, ages, still living with you? __________________________________________________________________________ __________________________________________________________________________ What do you want to accomplish in our work together? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ What would you be willing to let go of, or give up to handle these situations? __________________________________________________________________________ What are the reoccurring patterns in your life and how are they affecting you? How long have you continued these patterns (behaviors, relationships, types of jobs, etc.), and what was happening in your life when these patterns first appeared? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Have you ever been in counseling or psychotherapy? If so, how long and with what results? ____________________________________________________________________________ ____________________________________________________________________________ Have you ever been hypnotized? If yes, for what reason? ____________________________________________________________________________ How did you find out about us? ____________________________________________________________________________ In what setting(s) did you grow up? (City, rural, small town, military or other) ____________________________________________________________________________ Were you adopted? If so, at what age? ______________________________________________ How would you describe your childhood, including your home and school situations? ____________________________________________________________________________ ____________________________________________________________________________ Do you have early childhood memories before the age of 10? ____________________________________________________________________________ ____________________________________________________________________________ Do you remember any childhood traumas? Please describe. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Describe your relationship with your mother and father or other primary care adults in your life. Are they still living? Is there anything about them or your relationship that is important to know? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ What is your parent's marital status: (Still married, divorced, mother/father remarried, etc.) ____________________________________________________________________________ Other adults who had a part in your upbringing: (family members besides brothers and sisters, important teachers or role models-both good and bad). What was your relationship with them? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Names and ages of your brothers and sisters. Are they still living? Is there anything specific about your relationship with them that is important to know? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Do you make friends easily? ________________________________________________ Do you think about harming or killing yourself?_________________________________ Do you tend to repress your feelings?_________________________________________ Do you feel anger or resentment towards any person in your life? Why? ____________________________________________________________________________ ____________________________________________________________________________ Have you ever had an abortion or a miscarriage? If yes, how many? How
long ago? Was religion/spirituality an important part of your upbringing? Your
life now? Have you ever had a near death experience? If so, please explain. ____________________________________________________________________________ ____________________________________________________________________________ Have you ever had a psychic experience? If so, please explain. ____________________________________________________________________________ ____________________________________________________________________________ Do you remember your dreams? Have you had any out of body experiences? ____________________________________________________________________________ Are you following any regular disciplines? Meditation, yoga, martial arts, exercise, etc.? ____________________________________________________________________________ Do you seem to notice or experience anything as a constant in your life, and if so, does it prevent you from experiencing anything else in particular? ____________________________________________________________________________ What is your work situation? Do you enjoy your job and the people you work with? ____________________________________________________________________________
MEDICAL INFORMATION Doctor's name ___________________________________ Telephone ___________________ Are you currently under a doctor's care? If so, for what? ____________________________________________________________________________ Are you currently taking any medications? If so, what kinds? ____________________________________________________________________________ Do you have a history of: __Alcohol abuse __Drug use __Smoking __Eating disorders __Chronic pain __Fainting/blackouts __Insomnia __High blood pressure __Shortness of breath __Cancer __Dyslexia/Learning Difficulties __Diabetes __Hypoglycemia ___Aids If you checked any of the above boxes, please provide further information. Also include any other physical problems you may have experienced, including those of ear, eye, nose or throat, as well as any conditions of the spinal column, nervous system, reproductive system or elimination system. ____________________________________________________________________________ ____________________________________________________________________________ Testimonials about Heart & Soul Healing © 2023 Clear Light Arts, ADL
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