Metaphysical Healing Questionnaire

Name at birth*

Name most commonly used (if different from above):

Email*

Phone* (with area code)

Birthdate*
Month:

Day:

Year:

What is your occupation?*

What are the challenges you are having currently / What would you like to heal?*

How long have you been dealing with these issues?*

What was happening in your life around the time these issues surfaced?*

When you think about these issues, where does your body react?
Where do you feel the physical manifestations of the issues?*

What methods have you used to heal these issues and what has worked and not worked?*

In as much detail as possible, please share your childhood experiences with me especially
your relationship with your caregivers (parents, grandparents) and siblings and any other
family member that was a significant part of your upbringing.*

Who do you feel resentment toward? (can be more than one person, yourself, or experience)*

Who do you feel angry with? (can be more than one person, yourself, or experience)*

How do you judge yourself?*

In what ways do you carry shame?*

In what ways do you carry guilt?*

How do you punish yourself/beat yourself up?*

How do you self-soothe, self-medicate?*

How do you express / release your emotions?*

How do you care for yourself?*

What percentage of your day do you spend:
Ruminating about the past?*

Fearing the future?*

Being in the present moment?*

What are your spiritual beliefs?*

* denotes required fields