PRE-SESSION QUESTIONNAIRE

Before we meet for your Initial Consultation, please take a few minutes to complete this questionnaire.

It’s an essential part of the process as it helps me understand where you’re at and what you may be carrying beneath the surface.

It’s designed to gently bring awareness to what might be contributing to your exhaustion, overwhelm, or sense of feeling stuck, so that our time together can be as focused and effective as possible.

There are no right or wrong answers.

Simply respond honestly and from the heart.

Everything you share is held in confidence and personally reviewed by me.

Thank you!
PRE-SESSION QUESTIONNAIRE
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityCountry

Postal / Zip Code
Phone Number*

Country CodeArea CodePhone Number
Date of birth*

DayMonthYear
Date
Emergency Contact*
Emergency Contact Phone Number*

Country CodeArea CodePhone Number
Relationship Status*
Children*
Pets*
Profession*
How did you hear about me and the work of Internal Conflict Resolution?*
Are you currently seeing any other health care practitioner?*

YesNo
If Yes, select all that apply:

Medical DoctorPsychiatristPsychologistTherapistChiropractorOsteopathNaturopathNutritionistHerbalistMassage TherapistEnergy WorkerKinesiologistAcupuncturistOther
Do you have any medical conditions I should be aware of?*

YesNo
If yes, please describe:
If you have been diagnosed with a psychiatric condition, please provide more details about the specific diagnosis and any relevant information regarding your current treatment or medication.
Have you been diagnosed with any psychiatric conditions, or received treatment from a psychiatrist?*

YesNo
Have you been previously been diagnosed with a mental health condition?*

YesNo
If yes, please provide details including the specific diagnosis and the approximate date of diagnosis.
Have you been previously diagnosed with a mood disorder?*

YesNo
If yes, please provide details including the specific diagnosis and the approximate date of diagnosis.
Are you currently experiencing suicidal thoughts?*

YesNoSometimes
Have you ever attempted suicide in the past? *

YesNo
If yes, please provide any relevant details that you are comfortable sharing.
If you have previously attempted suicide or are currently experiencing suicidal thoughts, please understand that while I am committed to providing you with the best possible support, my ability to ensure your safety is limited in an online or remote setting. It is crucial to prioritise your well-being and seek immediate assistance by contacting emergency services or a local crisis helpline. If you are currently under the care of a mental health professional, please maintain open communication with them regarding your situation. Together, we can work towards your well-being, but it is important to have a comprehensive support network in place for any immediate or emergent needs. Please also note that the therapist is required by law to report any threats of harm made during the session, either to yourself or to another.*

I have read and understand the information above
Are you currently taking any prescription medications, over-the-counter medications, vitamins, or natural herbs?*

YesNo
If yes, please describe:
Please state your general practitioner, medical centre or other medical professional responsible for your care, and their contact details.*
I give permission for the therapist to contact the medical professional above in the event of a medical emergency.*

YesNo
On a scale of 1-10, with 1 being the lowest and 10 BEING THE HIGHEST, please rate where you are in the following areas: *
Briefly and being as SPECIFIC as possible, what is the reason you are here?*
For how long have you had this problem?*
On a scale of 1 to 10 (with 1 being a very neutral feeling and 10 feeling very intense), how intense are your feelings which are associated with the problem?*
With relation to the score above, does the intensity show up as*

a physical sensation in the bodya thought or scene in your mindboth
If you were to remember, what was happening 6 to 12 months BEFORE all this started that was intense, emotional, overwhelming or sudden?*
How SPECIFICALLY is that a problem for you? What does it STOP you from feeling, being, doing or having?*
What have you PREVIOUSLY done to resolve the issue? *
What is missing for you right now? (Don’t overthink the response to this question. Just write down the first thing that comes to mind) *
What makes the problem BETTER?*
What makes the problem WORSE?*
Do you/have you had problems with any of the following (select all that apply):*

LibidoOrgasm/sexual satisfactionSexual performanceMenstruation/menopauseFertilityNone of the above
What’s the very LAST thing that you do before you sleep at night? *
What’s the very FIRST thing that you do when you open your eyes in the morning?*
What is your relationship like with technology + social media?*
I don’t need to know any details – just answer YES or NO – has there been some kind of PHYSICAL or EMOTIONAL TRAUMA in your life?*

YesNo
What is the POSITIVE EMOTION or INTERNAL RESOURCE that if you were to have enough of it, would allow this problem to go away? *
What is it about working with me and the unique approach of internal conflict resolution that appeals to you?*
Do you recognise that your thoughts, emotions, images, and actions have a DIRECT EFFECT on the quality of your life?*

YesNo
Who's RESPONSIBLE to overcome the current challenges in your life?*
To what percentage are you responsible for the change in your life?
What are your expectations from me and/or our Initial Session?*
ACKNOWLEDGEMENT

By signing this form:
I understand that this is a holistic, integrative approach.
I recognise that my practitioner is not a licensed GP, Psychologist, Psychiatrist or Social Worker. The self-regulated holistic treatments and client-centered disciplines that she is trained in and in which she has experience doing include Coaching, Time Line Therapy® techniques, Clinical Hypnotherapy, Neuro Linguistic Programming (NLP), iRest®, yoga nidra, Somatic Resourcing, Havening and Bilateral Stimulation.
I understand that the education I am receiving is not a substitute for medical care, and I have been advised to discuss this process with any doctor or mental health professional who is taking care of me now, or in the future. Additionally, I should continue any present medical treatment and consult my regular medical doctor or mental health professional for treatment of any new or old conditions.
I acknowledge that I have provided true information and that failure to do so will adversely affect the process.
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