CLIENT QUESTIONNAIRE
Hi - Should you choose to have an appointment with Jill Jesson, these are some of the questions you are likely to be asked beforehand:
Consider what you are experiencing currently and what is still troubling you from the past
1. Name, address, email, contact numbers, age, date of birth, occupation
2. Current relationship status and how long have you been in the relationship
3. Number of dependents/children/parents etc.?
4. Reason for appointment? What is your goal?
5. If you take medication – what it is for/how much/how long have you been taking it?
6. Any health supplements – what they are for/how much/and for how long?
7. List all symptoms of the mind, body or soul stating how long you have had them for. Include skin conditions/sleep problems/repetitive negative thinking/grief/post traumatic stress/anxiety/fears/phobias/depression/self-harm/unfulfilled/empty/no life purpose etc.
8. Any relationship issues – abused/bullied/co-dependent/controlled/jealous/insecure/ lonely/deep withheld secrets/guilt/shame etc.
9. Any patterns of behaviour - obsessive/angry/passive-aggressive/manipulative/ negative/low self-esteem/no confidence/inferiority/superiority complex/self-loathing etc.
10. Any addictions – relationships/recreational drugs/prescription drugs/alcohol/food/etc.
11. Any allergies/sensitivities – animal dander/hay fever/dairy/wheat/gluten/seafood/ candida/etc.
12. About your diet/whether you skip meals/go for long periods without food/binge eat/are bulimic/eat mainly junk and fast food/eat healthy etc.
13. Have you any amalgam fillings? How many? And since when?
14. Have you had root canal treatment? How many? And when?
15. Do you exercise/how often/what form?
16. Any request for spiritual development – increased intuition/insight/chakra balancing/karmic/past life cleanse etc.
17. Have you any limiting beliefs?
18. Any regrets?
19. Is there something from your past you haven’t let go of?
20. Is there anything you are in conflict with? Past? Present? Future?
21. What is bothering you?
22. What are you not dealing with?
23. What are you in denial of?
24. What anxious or negative thoughts do you have about the future?
25. What are you fearful of?
26. Is there anything that you think you cannot resolve?
27. How would you describe your lifestyle? 1.Boring 2. Without purpose 3. Leisurely 4. Busy 5. Overloaded 6. Stressed 7. Hyperactive 8. Extremely manic 9. Exhausting 10. Depleted
28. Is there something missing from your life?
