Name:
Date of Birth:

Marital Status:

Single

Married

Divorced

Widowed

Children:	Name:	Ages:

Are you currently under a doctor's care for any medical problems:
Yes     No

Please describe:


Surgeries:

Medications:

Hospitalizations:

Medical	Yes	No
	Date	Problem
Psychiatric	Yes	No
	Date	Problem
Alcohol/Drug Treatment	Yes	No
	Date	Problem

Any Strong negative or traumatic events in childhood or adulthood?
Yes No

Please describe:

Family Social History

Childhood

Adult

(Please click all that apply)
Physical Neglect	Mother	Father	Spouse/Partner
Emotional Neglect	Mother	Father	Spouse/Partner
Physical Abuse	Mother	Father	Spouse/Partner
Emotional Abuse	Mother	Father	Spouse/Partner
Sexual Abuse	Mother	Father	Spouse/Partner
Abandonment/Rejection	Mother	Father	Spouse/Partner
Betrayal	Mother	Father	Spouse/Partner
Unresolved Death Issues	Mother	Father	Spouse/Partner

Other:

Education: (Click on highest level of educational degree completed)

High School

Some College

College

Graduate

Please click the areas you feel you have had or are currently difficulty with:

Depression
Anxiety
Obsessive/ Ruminative Thinking
Phobia
Post-Traumatic Stress Disorder
Feeling Spiritually Blocked
Unusual Spiritual Experiences
Psychic Attack
Physical Tension
Pain
Anger
Low Self-Esteem
Alcohol/Drug Addiction
Sex Abuse
Interpersonal Relationship Problems
Physical Health Problems

Do you have any prior experience with:

Self-Relaxation Techniques
Guided Imagery Processes
Meditation Type