Client Profile

Your Email:

Please Confirm Your Email:

Name:
Age:

Street Address:

Street Address:

City:

State:

Zip Code:

Home phone:
Cell:

Work phone:
Fax:

How did you hear about me?

What is your main focus for our work together?

How will you know that you are making progress? (What will you need to see, hear, or feel?)

What beliefs or emotional issues might you need to address?

Are you willing to take 100% responsibility for what you create in your life?

YesNo

Previous experience with therapy or consultation.

What personal development programs, seminars, or other trainings have you attended?

Are you currently in an intimate relationship or dating? Please describe your experience and level of satisfaction.

What is your sexual orientation?

Briefly describe your relationship/marital history:

Describe your current employment situation and level of satisfaction:

Do you smoke, drink, or take recreational drugs? If so, describe and indicate frequency.

Describe any illness/physical challenges you have had through the course of your life:

Describe any emotional challenges you have had throughout the course of your life:

What insights, if any, do you have about how the physical and emotional challenges might be related?

Are you currently under any treatment (physical or physiological) for any condition? YesNo

If yes, please describe.

Name and phone number of physician

Please list all children and their age:

Please list all brothers and sisters and their age:

Please provide the following information about your birth:

Date (month, day, year):

Place (town/state, country):

Exact time (see birth certificate):

Describe your relationship/history with your mother as honestly as possible:

Describe your relationship/history with your father as honestly as possible:

Have you ever experienced any form of physical or sexual abuse? If so, please describe:

Which set of words are you more comfortable with? Select Set A or Set B.

Set A: active, logical, linear, intellectual, willful, focused, goal oriented, individualistic

OR

Set B: receptive, intuitive, non-linear, emotional, surrendered, expanded, process oriented, collaborative

Set ASet B