Client Questionnaire

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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

Appointment Information

July 4, 2015

Touching Spirit Center LLC
845-217-7268      e-mail: TouchingSpiritCenter@gmail.com

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