Elizabeth K. Stratton, M.S.
Touching Spirit Center LLC
CLIENT QUESTIONNAIRE
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 ________________
Address_______________________________________________________
______________________________________________________________
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 _________________________________________________
Exercise______________________________________________________
Sleep ________________________________________________________
Tobacco, Alcohol, non-prescription Drugs _________________________
Caffeine ______________________________________________________
Bowels _______________________________________________________
Posture assumed most of the day ________________________________
Food
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
July 4, 2015
Touching Spirit Center LLC
845-217-7268 e-mail: TouchingSpiritCenter@gmail.com
Elizabeth K. Stratton 