Personal Assessment

You need not answer all the questions, but a fuller picture gives me greater clarity.
Name:
Address:
Email:
Age:
Sex:
Marital Status:
Children:
Occupation:
Spiritual Practice:
A brief description of your general state of health:
Do you suffer from allergies:
Do you have or have recovered from any major illnesses:
Have you undergone major surgery:
Brief description if you would like:
Have you experienced a major trauma such as:
Abuse (sexual, mental, verbal, physical):
Accident:
A difficult birth (your own):
A difficult time giving birth:
Been a victim of crime:
Been in a natural/industrial disaster or been in a war:
Death of a loved one:
Experienced long term stressful circumstances:
Have you been in a situation where you felt your life was in danger (whether it was really or not):
Witnessed a traumatic event:
Brief Description if you feel like it: Please be aware that talking about a traumatic event can bring up feelings or symptoms. Please stop describing if this happens.
Emotional Difficulties:
Are you in a difficult relationship:
Are you recently divorced or separated:
Are you recently bereaved:
Are you suffering racial discrimination:
Do you suffer domestic violence:
Do you suffer from mental health problems:
Do you suffer from addiction or eating disorders:
Have you recently had an abortion:
Have you been adopted:
Have you given up a child to adoption:
Brief Description if you feel like it:
Any other problem:
Thank you for sharing with me. All information provided is confidential. I will answer by email, giving any suggestions that may be helpful, or links to more direct information sources that may be of benefit to you. Juliet

Personal Assessment

You need not answer all the questions, but a fuller picture gives me greater clarity.

A brief description of your general state of health:

Have you experienced a major trauma such as:

Emotional Difficulties: