Chariea Aviya Wellness - Rapid Transformational Therapy

Chariea Aviya Wellness - Rapid Transformational Therapy
INTAKE FORM
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Health Information:
Doctor's Name and Contact Number*
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Health Problems*
Past and current
Presenting Issue

Please give details of what are the reason(s) you are seeking to be healed:
From this list below tick your areas of concern*
What specifically would you like to work on in our session?*
On a scale of 1-10, how would you rate this problem?*
Why?*
In relation to the previous question)

Please describe the symptoms and any triggers or habits you have as a result of the issue*
How often do you experience these?*
How long have you been dealing with this issue?*
What does this stop you from doing?*
How does this make you feel and why?*
What have you done to try to solve / change this issue? *
What work and didn't work?

Family Background:

Family of origin is important to insightful therapy and healing
Tell me about your childhood and how you were raised. Were you accepted with love, kindness, understanding and praised or were there trauma, constant criticism, or inability to express yourself? *
Please explaing
How was your relationship with your family and each member?*
Your mum and dad, siblings, before and now
If you have siblings, how many and where do you fit in?*
What additional information you would like me to know?

During your session, we will work together to discover the root, the cause and the reason for your concern/issue. The best part of my job is to help you to feel better. In order to do that. However, I need you to do your part and tell me exactly and specifically what it is that you want. Please focus on what it is that you want and not what you don't want (describe it as details as possible; seeing, hearing, feeling your future scenes).

If i had a magic wand and could grant you one wish during your session what would that be?

(Please be as specific as possible).
What Do You Want?*
Your Commitment: How committed are you in getting the result and why?*
from 0 - 10 with 0 just exploring and 10 extremely committed
DECLARATION:

The information which i am providing is the closest and most accurate description of my situation that i am able to disclose at this moment.

I understand that this therapy is a collaborative efforts and that the quality of the results are contingent and my own motivation and commitment to actively participate in my healing by following my therapist's recommendations and suggestions. Results can not be guaranteed, moreover, results from individual testimonials are for reference only and your own personal experience may differ to those shown on the site.

I understand root, cause therapy is an approach to treatment that focuses on resolving significant past events believed to be interfering with a person's present mental and emotional wellness. Only people with sound mental health who are confident that a review of past events will not adversely impact their emotional or mental health should participate. We request that you do not participate in root, cause therapy, if you have any pasts / existing concerns about your mental health.

I also acknowledge that all information I provide is fully confidential and it will be treated with care and respect by my therapist.
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Chariea Aviya Wellness - Rapid Transformational Therapy

INTAKE FORM

Health Information:

Presenting Issue

Family Background: