Questionnaire
All forms filled out and sent to me are held in strictest confidence and will not be shared with anyone unless you give written permission to do so.
Basic Information:
Full Name:
Birth date:
Name of city or place where you currently live:
email address:
Nature of Your Request:
1) Which of the following best describes your reason for seeking a consultation (there may be several choices):
i. Desire to communicate with a loved one who has passed away
ii. Physical healing Illness or Diagnosis:
iii. Emotional healing Issue or challenge:
iv. Clarification of decisions
v. relationship challenges
What is the relationship, mother, father, partner, child?
vi. Support for the direction of your business or work in the world
vii. Desire to connect with personal guidance
viii. Desire for greater overall health and well-being
ix. Healing loss
x. Other. Please elaborate.
2) What is your intention, or what do you hope to gain from this session?
3) Please list three questions for your private session relating to one or more of the above reasons for seeking a consultation.
Please answer the following questions as completely as possible.
Background & Health Questions:
1) Have you experienced a serious or life threatening illness in the past two years?
i. What was your diagnosis or the cause?
2) Have you experienced the loss of a loved one in the last 2 years?
3) Do you have a physical ailment? What part of your body is injured or painful?
4) Do you have beliefs that you are aware of that might be connected to your physical ailments?
i. If so, what are they?
5) Are you under the care of a therapist or psychiatrist?
6) Have you had any history of mental illness?
i. Diagnosis:
ii. Are you on medication?
7) Anyone in your family have a history of mental illness?
i. Diagnosis:
ii. Regulated by medication?
8) Do you think you are depressed?
9) What are your feelings in regard to answering these questions?
(For example, you might feel excited, grateful, angry, afraid, sad or something else.)
Thank you for completing this questionnaire. Just copy and paste it into an email and send it to Robin. rhlysne@cruzio(dot)com Don't forget to add times and dates that work for you. Once I confirms that I have received payment and your questionaire, I will email you back with time and date that works for me and the phone number (831) 457-2483.
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