PRIVATE AND CONFIDENTIAL



Abundant Energy Expert Showing you how to build more vitality, well-being and energy for life

Psychology Questionnaire

This questionnaire is designed to provide your practitioner with all the information necessary to build you an individual programme specifically tailored to your needs. Please answer all of the questions as accurately as you can. PRIVATE AND CONFIDENTIAL

|Full name:       |Date:       |

Psychologist/psychiatrist name and address if applicable:      

Current Beliefs Around Illness (if applicable). Please agree or disagree:

I want and desire to be healthy      

I believe it is possible to for me to be healthy      

I have or can learn the capabilities to be healthy      

It is an appropriate time in my life to be healthy      

The gains of being healthy outweigh the gains of remaining ill      

I am willing to change negative lifestyle patterns, thought processes and limiting beliefs      

Once I know how, I then hold the responsibility to be healthy      

I deserve (or I am good enough) to be healthy      

Current Social Relations

Do you have people who understand you and support you in your life and current situation?      

Do you feel safe, respected and valued by friends or a supportive social network?      

Do you feel emotionally supported and safe at home?      

If you are in a relationship, is this secure and supportive or is it stressful?      

Do you have other supporting health care professionals working with you?      

Are you a member of any support groups that are helpful?      

If you are working, is your social work environment supportive or stressful?      

If you have children, are you supported in looking after them

Adult Emotional Experience

What have been the most stressful periods of your adult life to date, and how do you feel they have impacted you?      

Emotional Illness Triggers

If you have an Illness, were there any psychological, emotional or social triggers that you think may have played a part in your illness onset?      

Your ACE Score

Calculate your ACE score here:

Total number of ACEs:      

Please list briefly what these were here:      

Your Enneagram Type

Complete the RHETI Personality Test here (cost $12):

Please put your results in the able below:

|Highest rated |Enneagram Type |Score |

|1 |      |      |

|2 |      |      |

|3 |      |      |

|4 |      |      |

|5 |      |      |

|6 |      |      |

|7 |      |      |

|8 |      |      |

|9 |      |      |

Epigenetic Intergenerational History

What was your mother’s emotional state like during pregnancy, and shortly after your birth?      

Did your mother suffer any emotional trauma during her life?      

Did your father suffer any emotional trauma during his life?      

Any emotionally traumatic events in your maternal grandparent’s life or related extended family?      

Any emotionally traumatic events in your paternal grandparent’s life or related extended family?      

I hereby confirm that this information is correct to the best of my knowledge and that I am not withholding any important information. I understand that neither a nutritional therapist nor a bioenergetic practitioner is able to diagnose or treat medical conditions. Neither nutritional advice nor advice from bioenergetic practitioners is intended to replace the advice of medical doctors. The treatment is not a substitute for the medical treatment of a doctor but it can work to complement it. If you have health concerns, always consult with a licensed medical professional first.

|Date: |      |Signed: |      |

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