Client Questionnaire

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Elizabeth K. Stratton, M.S.
Touching Spirit Center LLC

In order to maximize the time and effectiveness of your session, please fill out this questionnaire and either mail it back with your check or bring it to your first appointment.

Name __________________________________ Date ________________



Home Phone ______________________   Work Phone ________________

Current Occupation _____________________________________________

Date of Birth _________________________ Referred By ______________

Presenting Issues _______________________________________________

Are you under a doctor’s care? Receiving medical treatment? ________________________________________________________________________

Do you have any experience with holistic therapies? Which ones and were they helpful? ____________________________________________________________________


Psychotherapy, psychoanalysis, counseling or psychiatry? Please describe. _______________________________________________________________


Daily Routine _________________________________________________


Sleep ________________________________________________________

Tobacco, Alcohol, non-prescription Drugs _________________________

Caffeine ______________________________________________________

Bowels _______________________________________________________

Posture assumed most of the day ________________________________


Breakfast _____________________________________________________

Lunch ________________________________________________________

Dinner ________________________________________________________

Snacks ________________________________________________________

Medical History (Please indicate with a checkmark any medical problems, and describe in detail.)

______ Pain

______ Heart Condition

______ Cancer

______ Accidents, Injuries

______ Skin Condition

______ Joint and/or Bone Problems

______ Neurological Condition

______ Stress, Depression, Anxiety, other Emotional Difficulties

______ Digestive Problems

______ Surgeries (please list: _______________________________________)

List any medications you are currently taking and for what conditions they have been prescribed. _______________________________________________________________________


Names, addresses & phone numbers of health care providers:  _____________________________________________________________________


Do we have your permission to contact your physician if the need should arise?  ________

What does “healing” mean to you?  _____________________________________________________________________


What would your healing appointment need to provide for you to consider it successful?



Spiritual healing and the laying-on-of-hands do not replace medical care; yet can be used as an adjunct therapy to mobilize inner healing responses.

Please sign and date below to acknowledge that you understand this statement, and that all the information in this questionnaire is correct.

Signature                                                                   Date

Appointment Information

July 4, 2015

Touching Spirit Center LLC
845-217-7268      e-mail:

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