BEGIN YOUR HEALING JOURNEY. “Those only are the brave that keep their ground, and keep it to the last.”-Robert Blair Energetic Client Questionnaire. Name * First Name Last Name Date of Birth: * Time of Birth: Place of Birth: Type of Birth: Do you have any children? Pets? What kinds of foods do you eat? What is your favorite place to relax? What is your favorite pastime, activity? Do you have any addictions? If the answer is yes, are you in recovery and for how long? Are you on any medications or do you have a mental health diagnosis? If you are on medication, please list them and how long you have been taking them? Would you prefer to use alternative/traditional methods for your health care needs or Western Medicine? Have you ever been diagnosed with a mental illness? If yes, are you on any medication? Do you have a chronic illness? Have you ever been hospitalized? Do you prefer to work/collaborate in teams or alone? Are you a people pleaser? Are you an extrovert or an introvert? How many siblings do you have? Have you ever had a near death experience (NDE)? Have you experienced loss in your family or someone close to you? What problems do you have that you consider manageable? Do you believe in a higher power? What do you like to do creatively, rather how do you like to have fun? Are you a night-owl, or an early-bird? When you do rise, what is your daily routine? (if you have one) What do you consider to be your assets, traits or habits you like about yourself? What are your current life goals? Do you have a faith based practice, go to church/synagogue or mosque? What are your character defects/aspects you don’t like about yourself? Did you have any major accomplishments or goals achieved in 2023? Who or What would you credit for keeping you balanced? What do you do to relieve tension, stress or anxiety? Where would you like to be creatively, financially & emotionally in the next 3 months? On a day of rest and relaxation what does your schedule look like ? What do you want to do? What in your life is your greatest accomplishment? Are you familiar with an Ego death and do you believe you have ever experienced one? Where would you like to be and what do you want to achieve in the next 5 years? Have you ever worked or been treated by an Alternative or Traditional Practitioner/Shaman or Healer? If yes, did you have a positive or a negative experience, please explain. What is your profession now? Would you like to do something else to create your income? Email * Thank you! ALL RESPONSES ARE CONFIDENTIAL Rev. Micaela Córdoba El Shaman/Medical Intuitive & AlchemistGet Well Collective LLC.
