Elizabeth K. Stratton, M.S.
Touching Spirit
Center LLC
CLIENT QUESTIONNAIRE
In order to maximize
the time and effectiveness of your session, please fill out this questionnaire
and bring it with you to your first appointment.
Name __________________________________ Date ________________
Address ______________________________________________________
_____________________________________________________________
Home Phone ______________________ Work Phone ________________
Current Occupation _____________________________________________
Date of Birth _________________________ Referred By ______________
Presenting Issues _______________________________________________
Are you under a doctor’s care? Receiving medical treatment? ___________
_____________________________________________________________
Do you have any experience with holistic therapies?___________________
_____________________________________________________________
Psychotherapy, psychoanalysis, counseling or psychiatry? ______________
_____________________________________________________________
_____________________________________________________________
Daily Routine _________________________________________________
Exercise______________________________________________________
Sleep ________________________________________________________
Tobacco, Alcohol, non-prescription Drugs ___________________________
Caffeine ______________________________________________________
Bowels _______________________________________________________
Posture assumed most of the day __________________________________
Food
Breakfast _____________________________________________________
Lunch ________________________________________________________
Dinner ________________________________________________________
Snacks ________________________________________________________
Medical History (Please indicate with a checkmark ü any medical problems.)
______ Pain
______ Heart Condition
______ Cancer
______ Accidents, Injuries
______ Skin Condition
______ Joint and/or Bone Problems
______ Neurological Condition
______ Stress, Depression, Anxiety, other Emotional Difficulties
______ Digestive Problems
______ Surgeries (please list: _______________________________________)
List any medications you are currently taking and for what conditions they have been prescribed.
_____________________________________________________________
_____________________________________________________________
Names, addresses & phone numbers of health care providers:
_____________________________________________________________
_____________________________________________________________
Do we have your permission to contact your physician if the need should arise?________
What does “healing” mean to you?
_____________________________________________________________
_____________________________________________________________
What would your healing appointment need to provide for you to consider it successful?
_____________________________________________________________
_____________________________________________________________
Spiritual healing
and the laying-on-of-hands do not replace medical care; yet can be used
as an adjunct therapy to mobilize inner healing responses.
Please sign below to
acknowledge that you understand this statement, and that
all the information in
this questionnaire is correct.
_____________________________________________________________
December 20, 2006
The
Touching Spirit Center Home Page
Touching Spirit Center LLC ·
P.O. Box 337 · Litchfield, CT 06759-0337
860-567-0600 · website:
www.touchingspirit.org
· e-mail: TouchingSpiritCenter@msn.com