Aligning Energies Intake

When filling out this form, the * means an answer is required. If answering a particular question is difficult or uncomfortable, just put "TBD" for "to be discussed."


1. Identifying information:

Date of Birth:

2. Check any of the following goals which seem particularly important to you right now:
    Connect with your own inner guidance
    Develop skills in energetic and emotional awareness and self care
    Heal old wounds
    Reduce pain, fear and other forms of suffering
    Free yourself from limiting beliefs and habits
    Resolve inner conflicts
    Clear ancestral, past life and archetypal entanglements
    Develop inner resources for confident and effective action
    Identify and develop core values and deep wisdom
    Increase your capacity for enjoying life

3* What is the realm of greatest concern for you?
   
   
   
   

4* What is your primary goal for Aligning Energies work at this time?

5* Prior experience with energy healing, bodywork, psychotherapy or hypnotherapy:

6* Religious orientation & spiritual practices such as meditation, prayer, shamanic journeying:

7* Current family/relationship/community status:

8* Occupation and job satisfaction:

9* Recreation, exercise, connection with Nature:

10* Relevant personal history: (Note briefly any events or conditions in your life that may be related to your current concerns, such as a history of abuse, or early loss of a parent)

11* Current symptoms (physical, mental, emotional):

12* Current medications or substance use (tobacco, alcohol, recreational drugs):

13* Health history: major accidents, surgeries, illnesses, substance use:

14* Current or recent stresses, constraints, demands, changes:

15* Subjective assessment of overall health and happiness:

16* Amount of time you are currently willing and able to spend daily on energy self-care homework following your Aligning Energies sessions:
   
   
   
   
   

17*  I am familiar with the Basic Principles and Potential Benefits of Aligning Energies work. (Please read this information from the web site.)
18*  I have read the Session overview and additional information on:
    Telephone sessions and/or
    Office sessions.
19*  I understand the information on fees, confidentiality, and scheduling and preparing for sessions in those documents.

20. I have these questions, concerns or comments:

21*  I have read and understood the terms of the Informed Consent and I consent to them.

22.  I would like to schedule a free 30-minute consultation with Cerridwen.

23. I would like to schedule my initial  Telephone    Office session with Cerridwen.

24. Good times and days for scheduling sessions (generally speaking):

  Mo Tu We Th Fr Sa Su
Morning
Afternoon
Evening

25. My Time Zone is: Other:

26. Anything else you want to say or ask:

Date:

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