Health & Life QuestionnaireEvery journey begins by taking the first step. Name * First Name Last Name Email * Phone (###) ### #### 1. What areas of your life are you having difficulties with? (ie. Money, Career and Money, Craft/Occupation, Health and Body, Intimate Relationships and Family.) 2. How long have you been struggling with each area you listed above? 3. How are you doing mentally and emotionally in general? 4. If you've been struggling mentally and emotionally, how long have you been struggling for? 5. What type of providers, treatments or modalities have you sought out to remedy your struggles? 5b. Which of the above do you feel helped you, if at all? 6. What do you feel is the reason for the struggles or problems you're having? 7. What have other practitioners or providers said about your struggles? Do you agree or disagree with their assessments? 8. Are you still seeing your practitioner? If not, what did you feel is missing? If you are, what additional help are looking for to feel that you are properly taken care of? 9. Do you feel the physical areas of struggle are related to any mental/emotional stress? If so, please describe. 10. Have you experienced any kind of physical, emotional or sexual trauma from your past? If so, how do you feel this has affected you in your life? 11. How motivated are you to take action and find a solution for your struggles on a scale from 1-10? 12. If you’re interested in scheduling a session with Harold, please list some days and times that are good for you. 13. If there anything else you would like to share, please do so below. Thank you. Every journey begins by taking the first step. *This form is sent directly to Harold, so no need worrying that anyone else will see what you’ve shared.
