First and Last Name
*
First Name
Last Name
Birth date
MM
DD
YYYY
Email address
1. How did you hear about my services?
2. Please share briefly what is your motivation to seeking counselling at the moment.
3. What are the main goals that would you like to achieve through our work together?
4. How are you currently supporting your inner work at the moment?
5. Please share your previous experience with counselling/therapy process. Have you been in a process before? If so, what kind, for how long and what were you seeking to solve through that process
6. Do you consider that the process was successful? Why?
7. Are you currently dealing with any physical/medical condition? If so, which one(s)?
8. Are you currently taking any medication or supplements? If so, which one(s)?
9. If applicable, what does your menstrual cycle mean to you & how is your experience of it?
10. If applicable, at what age did you have your menarche? What did it mean for you?
11. If applicable, do you change your life(style) in any way when you bleed?
12. Is there anything else you would like to add?
