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Cyclic Wisdom Relationship Counselling Form

First and Last Name

First Name

Last Name

Birthday

YYYY

Phone

Country

(###)

###

####

Address of residency

1. How did you hear about my services?

2. How familiar are you with counselling? How has your experience been?

3. What is the reason for seeking Cyclic Wisdom - Relationship Counselling - and what do you hope to achieve?

4. For you, your partner and your relationship to heal, gain insight and compassionate understanding, requires 100% commitment. Please share what you need to support your full commitment, to trust in yourself and your relationship.

5. Please let me know how safe, seen, soothed and supported you feel in your relationship. We all have four fundamental needs that we seek to fulfill in relationship. a) The need to be safe emotionally and physically. b) The need to be seen, heard and understood. c) The need to be soothed, comforted and acknowledged, and d) The need to be supported and challenged in life-affirming ways.

a) How safe do you feel from a scale of 0 to 10

b) How seen, heard and understood do you feel from a scale of 0 to 10?

c) From a scale of 1-10, how soothed and comforted are you?

d) From a scale of 1-10, how supported do you feel?

6. Please consider how safe, seen, soothed and supported your partner feels in relationship with you.

a) how safe does your partner feel with you? (scale 1 to 10)

b) how seen does your partner feel by you?

c) how soothed does your partner feel by you?

d) how supported does your partner feel by you?

7. In a short paragraph, describe the behaviour your partner does that has a tendency to trigger you, and maybe drive you crazy.

8. Please share HOW YOU FEEL when your partner does that triggering behaviour. (I am not asking for your opinion, assumption or interpretation of his/her behaviour. I want to know how YOU FEEL..

9. Trust whatever wants to come forth for the following questions.

a) What may be the root cause of you getting triggered by your partner's behaviour?

b) What need is your trigger trying to meet?

c) Out of curiosity and compassion, please guess or intuit what may be the reason behind your partner's behaviour.

d) Without taking on any self-blame, what are your actions, words and gestures that may be contributing to your partner's behaviour? 10

Thank you for the time and care that you put into answering these questions, for being willing to look into your needs and the needs of your partner, and for making the commitment to this healing process.