Personal History
The more you know about you, the better I can personalise your intervention plan. Each question will give me insight into what has happened, and how the symptoms are being created. We will go through these questions in more detail in our first session together. Yes, there are a lot of questions, but they help build your life picture, and what you would like to create instead. Remember, nothing changes unless we change.
Name
First Name
Last Name
Email
example@example.com
Date
-
Year
-
Month
Day
Date
Why are you here? Brain dump all the reasons why you are here
How do you know you have this problem?
How long have you had it?
Tell me about your parents, brothers, sisters etc. What is the relationship between this person (mother, father etc., and your current situation?
Tell me about your childhood in relationship to this problem?
How will you know when this problem has totally disappeared?
What do you need to do that you don't want to do?
What do you not want to do that you must?
What is the relationship between this problem and problems you have in other areas of your life?
Will any of those problems stop you from solving this problem?
How will you know specifically that the problem is gone?
What wouldn't happen if you didn't have the problem?
What do you say to yourself when you look in the mirror? What do you see and what do you feel?
Agreement to play 100%
Do you want to and are willing to get rid of, resolve& clear the problem NOW?
Yes
No
Not sure
What is it that you have been holding on to and are now willing to give up to get your desired result?
IF No, what are your concerns or reservations?
Are you prepared to do whatever it takes to resolve & clear the problem NOW?
Yes
No
Not sure
Is there anything that you would not do or that would stop you from playing at 100% to get your desired outcome? If yes, what is it?
Is it important to you and really, really worthwhile to resolve your problem NOW
Yes
No
Not sure
What will be the benefits to you or what do you get out of achieving your desired result?
Your Signature
*
Date
-
Year
-
Month
Day
Date
Submit
Submit
Should be Empty: