Client Questionaire

Janet StraightArrow’s BE THE MEDICINE

Confidential Client Information Form

Name: ____________________________ Age: ______ Today’s Date: _______________

Street Address: ________________________________________________________________________

City: __________________________________ State: _________ ZIP: _______________

Phone (home): ________________ (work): _____________

(cell): ____________________________________

E-mail: __________________________________________________________________

Emergency Contact Name: ________________ Number: ___________ Relation:________

Birth date, time, place: ______________________________________________________

Birth information of anyone else important:______________________________________

 

 

  • How did you hear about me?
  • Are you seeing any practitioners or therapists at this time or about issues today?

___ Yes  ___ No

  • If yes, medical, spiritual, energy, psychological, chiropractor, acupuncturist, other?
  • Have you experienced Shamanic or Intuitive Energy Work before?

___ Yes  ___ No

 

  • If yes, for what reason and when?

 

 

  • Are there any medical conditions or specific medical problems that you are experiencing at this time? Explain.

 

 

  • Are you taking any medications at this time?

___ Yes  ___ No

  • If yes, what are they and why?

 

 

  • What are you here to work on today?

 

 

  • Have you had any car incidents or surgeries?

___ Yes  ___ No

  • If yes, what are the dates and what occurred?

 

 

  • Have you had any major losses due to death, divorce or separation?

___ Yes  ___ No

  • If yes, when and what relationship to you?

 

 

  • Have you had any traumatic events you are aware of?

___ Yes  ___ No

  • If yes, when and what happened?

 

 

  • Current profession:  __________________________________________________
  • Do you enjoy your job?

 

 

Family History:

  • Relationship Status: __________________ Length of Relationship: ____________
  • Indicate your current living situation: _____________________________________
  • Ages of any children:
  • How would you describe your family/social life right now:

 

 

  • How would you describe your childhood / relationship with parents?

Health:

 

 

  • Any history of major illness/health problems/mental or emotional concerns?

 

 

  • How is your overall health at this moment? Explain.
  • What physical symptoms are you experiencing now or in the past?
  • Please circle those that are appropriate and describe below:

Headache – Sleep problems – Allergies – Diabetes – Blood Pressure – Heart – Nausea – Pains – Food allergies

Circulation – TMJ – Pregnant – Cancer – Menopause – Menstrual Cramps – PMS – Back – Joints – Physical aches

Specific details, any diagnosis and/or any unlisted items:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

  • What foods do you currently eat on a daily basis?

 

 

  • Have your eating patterns or your body weight ever been a concern for you? If so please describe:
  • Do you have any family patterns of disease, addiction or illness? List:

 

 

  • Do you currently perceive stress, anxiety, panic, fear, sadness, anger, guilt, shame, depression or feeling stuck?  Have you been affected in the past? Explain.

 

 

  • Have you ever been hospitalized for physical health, mental health or substance abuse treatment?  If so, list reason and dates.

General Knowledge:

 

 

  • What do you do to balance and energize yourself now?
  • Do you practice meditation, breathing, exercise or spiritual practices?

___ Yes  ___ No

  • If yes, what forms and how frequently?
  • Are you sensitive to energies or feel you have taken on energies from other people or environments? Describe.
  • How would your life be different with this problem solved?

 

  • Have you ever had significant personal growth experiences in the form of special trainings, workshops or related experiences?

 

 

  • What are your greatest strengths, talents and resources?

 

 

  • What do you want to do that you are not able to accomplish at this time?

 

 

  • What other things would you like to work on?

 

 

  • Any questions?

 

 

 

PLEASE GO THROUGH THIS FORM AGAIN AND USE THE BACK AND ADDITIONAL PAGES TO REPORT ANY RELEVANT INFORMATION ABOUT YOURSELF THAT WILL ASSIST IN MOVING YOU FORWARD.

I understand some things are best spoken and not written so feel free to allow for this also. Blessings, Janet

 

Client Signature

Date

 

Intuitive Counseling, Energy and Shamanic Healing are often used in conjunction with more common physical, mental and emotional healing modalities. They are not intended to take the place of conventional health care options.

Janet StraightArrow

Be The Medicine * 973-647-2500

18 Bank St, Morristown NJ 07960

http://www.bethemedicine.com

 

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