Design Your Mind for Success

Pre-Consultation & Therapy Treatment Questionnaire.

Please take your time to answer these questions fully and remember that I provide ‘complementary therapy treatments’ and that these treatments are not a replacement for you seeking medical consultations and treatments from your GP for physical ailments.

If you require further assistance or have any further queries, please call 07981-277329 or email designyourmindforsuccess45@gmail.com

Please ensure the form is completed at least 48 hours prior to your session.

Please read the Disclosure and Agreement.

A 50% non-refundable deposit is required to secure your appointment.

Cancellation policy: must provide 24 hours notice unless an emergency.

Bank Details

  • Design Your Mind For Success
  • 04-03-70
  • 91271427
Consultation Form
Name
Name
First
Last
What is the problem/limiting belief for which you are seeking my help? (What is your fear or what is holding you back & how is it a problem for you?)
How long have you had this problem & how did it begin? (be as specific as you can)
What have you done to address/get rid of the problem(s)?
If you’ve not done anything – please explain your reasons.
Did those things you previously did to address/get rid of your problem & if so how?
How Often Do You Think About Your Problem?
How Intense Are The Feelings Of Your Problem?
On a scale of 1-10 how intense are the feelings which are associated with your problem?
Emotional Feelings You Experience
If there are any emotional feelings present for example, guilt, anger, sadness, fear, hurt, joy, peace, happiness, rage, then please state below.
Can You Get In Touch With These Emotions As We Talk?
Have You Heard That You Have An Unconscious Mind?
How will you know that the problem has disappeared at the end of our treatment session(s)?
What will you feel?
How will your family/friends/business associates react to you letting go of your problem?
Will You Take Action?
As a client I may ask you to actively engage and complete tasks prior to and after your treatment that will enable fast and effective results.
Will you be proactive and take action / follow the tasks through?

COMMITMENT

I invest 100% of my time and energy to help you to resolve your issue(s) and you must be prepared to invest 100% of your time and energy to resolve your issue(s).

We are a team!

Are You Willing To Do That?
Are you willing to invest and fully commit 100% of your time and energy to resolve your issue(s)?
How Ready Are You To Get Rid Of Your Problem Now?
On A Scale From 1 To 100, How Ready Are You To Get Rid Of Your Problem Now?
What level of commitment do you have right now?
How Did You Find Out Or Hear About My Services?

Client Disclosure & Agreement

Before we begin, please read this agreement and tick the box below to accept it.

This will let us know that you have read and that you understand what is written here.

This form asks you about your present condition for which you seek therapy as well as any other issues you might have. It also sets out the context in which you will get the outcome you want. It also covers some of the issues of law governing our relationship.

Client Disclosure & Agreement
Please read and agree to the Disclosure and Agreement