If you are scheduling an emotional healing consultation for a phone or office visit, print this page and once completed... Call the clinic for specific instructions for faxing in your questionnaire.

This questionnaire is meant to stimulate your mind and heart, and to help prepare you to talk about who you are today and why/where you have come from.

Feel free to share as little or as much as you like here. We will talk more in person about all that matters most.

It would be helpful if you mail it in prior to your visit, but not critical. Please do bring this with you to our first session if you haven't sent it ahead of time.

Please copy or print this page and once completed, mail to the addresse at the bottom of the page. If doing a phone consultation you may fax the completed questionnaire to our office prior to your phone visit. Please call for instructions and our fax number.

Thank you.

Name___________________________ Phone #___________________  Date__________

Marital Status:

How many times have you been married?

Children (names/ages):

Current Occupation:

Highest Education:

1. What would you say is your biggest struggle currently?

2. What do you find is your prevailing attitude? (ex. hope, despair, depression, anger, faith, critical, love)

3. What attitudes are you most known for? How would the people closest to you have answered the previous question?

4. Who do you struggle with the most in your heart?

5. What feelings do you find yourself most overwhelmed with?

6. What event or person has been the most difficult for you to forgive in your life?

7. What three things would you change to make your life 'most perfect' ?

8. Explain the difference that God makes/has made in your life.

9. Please tell me anything else of significance to your heart and life that you have not already discussed here.

New Hope Health Clinic - 121 South 2nd Street - Jenks, OK 74037

Call Toll Free:  1-877-544-4673 

Emotional Healing

 

To explore our web site click here...

HOME