New Patient Form - Emotional
Street Address Line 2
State / Province
Postal / Zip Code
Phone Number (home)
Phone Number (mobile)
Date of Birth
Overall Health (choose one)
Are you any taking medications/drugs?
Are you taking nutritional supplements?
History-list any major illnesses, surgeries, accidentals, and/or emotional trauma:
Number of children if any:
For Pathway Reset Appointments ONLY - Choose ONE from the following list that you want to work on in your Pathway Reset Appointment:
grief & loss
For All Other Appointments - What are the top 3 issues you want to work on in your Emotional Healing Program.
How is this issue(s) affecting your life (problems, challenges, circumstances, relationships)?
List what you have done so far to try to resolve the problem. Are you currently working with anyone else to resolve it?
How long has this been a problem or struggle in your life?
Tell me about your family and childhood as it relates to the current situation (what is the relationship between your past experiences/ people and the current problem):
How will it feel/look in your life when the problem is gone? (i.e., goals and dreams; if you could have anything you want, what is it? Expect miracles...)
On a scale of 1-10, how committed are you willing to be with your time, energy and resources towards overcoming this problem (1 being the least committed and 10 being the most)?
1 is Least committed, 10 is Most committed
Should be Empty: