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:

  • any traumatic or dramatic events, such as broken relationships, lost jobs or accidents
  • death of family members and/or close friends, and how you handled the loss
  • hospital stays, including any surgeries
  • severe disappointments or rejections in your life
  • describe how you would like your life to be and how that is different from the way it is now; explain how would you like you to be different
  • Upon completion of this form, please mail it back to us at Post Office Box 1500, Cleveland, GA, or FAX it to 706-223-0291. You can also E-Mail (instructions here) your completed questionnaire. However: Do not include your credit card number in any e-mail as this is not secure. You will need to call us by phone to provide credit card data.

    Please enclose your payment of $145.00 USD. This fee includes the cost of evaluating your intake sheet as well as the one hour phone session. You are responsible for the 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.
    Credit card charges appear as: Clear Light Arts, ADL.

    Credit Card Number: ________________________________________ Exp. Date:_________

    Name as shown on card:______________________________________________________

    Signature of card holder_______________________________________________________

    CONFIDENTIAL INTAKE SHEET (PLEASE PRINT)
    **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:
    __Allergy/asthma   __Heart disease  __Chronic Fatigue Syndrome

    __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.

    ____________________________________________________________________________

    ____________________________________________________________________________

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