*Today's Date

    *Your Full Name

    Child's Name (if applicable)

    *Your Age

    *Marital Status

    * Your E-mail

    Cell Phone #

    Other Phone #

    Street Address 1

    Street Address 2



    *Zip Code


    Describe any pain, stress or disease issues affecting you now:

    Describe your health history – all significant diseases or injuries you have been through in your life:

    Instructions: Please write what you want to express for each question. Please be as open and honest as possible. All your answers will be held as strictly confidential and not shared with anyone else. Usually your first impressions are the best, so don’t over-think or analyze these questions, just let your replies flow right away.

    1. If you didn’t have to figure out the “how to”, describe what your life and health would look like and would be like, without stress or pain.

    2. What is most important to you now, and what you are seeking healing for?

    3. How would life be better if you resolved your current issues?

    4. What are your most urgent pains, issues or traumas that brought you here?

    5. What are any other pains, issues or traumas that might not be as urgent, but that concern you?

    6. How have these pains, issues or traumas affected the following areas of your life in a negative way:

    a. Your Job / Work / School:

    b. Your Intimate Relationships:

    c. Your Relationships with Family & Friends and Your Social Life:

    d. Your Finances:

    e. Your Spirituality:

    f. Your Leisure and “Fun” Activities / Hobbies:

    7. On a scale of 0 – 10 (10 being highest pain/stress level), what level is your pain or problem today? (This could be physical, mental or emotional issues)


    8. How would you rate your level of satisfaction with your health or life the way things are right now, on a scale of 0 – 10 (10 being not good, 0 perfectly satisfactory)?


    9. What other methods have you tried already in an attempt to change and/or get well?

    10. What do you imagine your life will be like in 5 years if nothing changes from the way it currently is?

    11. What is your MOST URGENT problem of all?

    12. What is stopping you from moving on from where you are now, and getting to where you would like your life or health to be?

    13. What is the biggest obstacle or challenge in your way?

    14. Is there any reason either conscious or unconscious that you can think of … any part of you that may have a reason for NOT changing, for NOT getting healthy? Please describe.

    15. On a scale of 1 – 10, with 10 most urgent, how important is it for you to do something about your situation now?

    16. Which of these 3 describes your readiness to do something about the pressing or urgent issues you described in this questionnaire:I am “not ready” yet to do anything about these issuesI am “getting ready” yet to do something about these issuesI am “totally ready” NOW to commit 100% and make my health and life fulfillment a top priority

    17. Which is true for you?I am “not ready” yet to invest time and money into resolving these issuesI am “getting ready” to invest time and money into resolving these issuesI am “totally ready” NOW to invest time and money into resolving these issues

    18. Is there anything else you would like to share with Darren now?