RECALL HEALING INTAKE FORM

RECALL HEALING INTAKE FORM

AHA Coaching
PART 1: PERSONAL INFORMATION
Basic Details & Contact
Full Name (if different at birth, include both)

First (Middle) NameLast Name
Telephone
Please enter a valid phone number.Format: (000) 000-0000.
E-mail
example@example.com
Place of Birth
Birth date and time (if you know)

DayMonthYear
Date
MinutesAM/PM Option
Age
Year/month - be precise
Completed Studies (Education) & field of study / qualification
Current occupation / Main Professional Activity
Satisfaction with your work (1 = very dissatisfied, 10 = very satisfied)
Main passions
Strong dislike
Family Background

Parents, Reproductive History/Children/Age of Independence, Relationship Status
YOUR PARENTS
Father's Date of Birth

DayMonthYear
Date
Mother's Date of Birth

DayMonthYear
Date
Father's age at your birth
Year/month - be precise
Mother's age at your birth
Year/month - be precise
Parents’ wedding date (if applicable)

DayMonthYear
Date
REPRODUCTIVE HISTORY
Number of Miscarriages – you
If male, please include your partner's
Number of Miscarriages – your mother
Abortions – you
If male, please include your partner's
Abortions - your mother
CHILDREN
From eldest to youngest
AGE OF AUTONOMY

Age when fully independent from parents (independent from food, money and shelter). It is usually when moving out, getting married, starting a job and contributing to the rent, bills, etc.
Years/Months
MARITAL/PARTNERSHIP STATUS
Status
Date of marriage/partnership (if applicable)

DayMonthYear
Date
Date of separation/divorce (if applicable)

DayMonthYear
Date
Reason for Consultation

Health/Behaviour/Emotional Context
Primary Reason for consultation
If illness – medical diagnosis and precise body location
Dominant Hand
Age/date when condition or problem began
Be as precise as possible
Major life events or shocks preceding the condition (positive or negative)
Greatest negative shock or traumatic event in your life
Significant fears and frights
Strong emotional triggers or recurring annoyances
Remorse or regrets you carry
Do you carry a heavy secret you have never shared with anyone
If yes, describe if comfortable doing so
PART 2: PROJECT/PURPOSE – Pre-birth & Early Life

9 months before conception, Conception, Pregnancy, Delivery and the First Year
What do you know about your parents’ lives before your birth and your early childhood? Give as many details as possible!

If you don't have information, leave the field blank – even partial answers are helpful.
Up to 9 months before your conception:
At the time of your conception:
Pregnancy experience:
Delivery experience:
First year of life:
PART 3: LIFE TIMELINE

Please write the major events of your life (dramatic events, trauma, shocks, fears, etc.), starting from “Now” backward to the “Birth”. Write everything meaningful that you can remember. Include age, date, event, and feelings as examples. Be as specific as possible. If you don't remember the date, put the month, season, and year.
Major events of your life (from now back to birth) – Very important!!!
Should be Empty:

RECALL HEALING INTAKE FORM

PART 1: PERSONAL INFORMATION

Basic Details & Contact

Family Background

Reason for Consultation

PART 2: PROJECT/PURPOSE – Pre-birth & Early Life

PART 3: LIFE TIMELINE