Please fill out the following questionnaire to help me get to know you. At the end there is space to tell me as much as you like about the issues that you would like to consult about.

Before filling out the questionnaire, please remember that:

  • you must not be suicidal
  • you must have read the legalese agreements.
  • payment must be received in advance.

Please do not submit the questionnaire if you do not meet these criteria.
 
1. Name:
   
2.E-Mail Address:
   
3. Age and gender:
   
4. Location:
   
5. Marital Status:
   
6. Occupation:
   
7. Educational history:
   
8. Have you ever been in any form of counselling, coaching or psychiatric treatment?
Yes No If so, please describe:
   
9. Any medical problems?
Yes No If so, please describe:
   
10. Any current or past psychiatric medications (e.g antidepressants, sleep aids)?
Yes No If so, please list:
   
11. How much exercise do you get? Please describe.
   
12. What are your main hobbies? Also, list some of your favourite books, films and music.
 
13. Tell me about your sense of spirituality.

 

14. What kind of issues would you like to talk about? Also, tell me a little about yourself and your background.
   
I have read & agree to the Informed Consent in the legal section of the website
I have read & agree to the Privacy Statement in the legal section of the website