Client Information
This questionnaire in an editable format will be emailed to you once an appointment is arranged
<< All the information in this questionnaire will be kept private and confidential >>
Client Information
<< All the information in this questionnaire will be kept private and confidential >>
Personal Details
Name:
Date of Birth:
Address:
Phone Number:
Email;
Emergency Contact Name:
Emergency Contact Phone Number:
Relationship Status
☐ Single ☐Living Together ☐Married ☐ Widowed ☐ Separated / Divorced
What is your present employment and area of work?
If you had access to $10 million, what would you love to do?
Medical Information
Please describe any serious illnesses, accidents, or injuries
Please list any medication that you are currently taking and for what aim
Indicate any drugs you use
☐Alcohol ☐Nicotine ☐Marijuana ☐Psychedelics ☐Opiates ☐Amphetamines ☐Other
Frequency of use;
☐daily ☐weekly ☐monthly ☐yearly ☐occasionally ☐binges ☐Other
Mental Health Information
Are you currently in counselling elsewhere? ☐Yes ☐No
Have you had previous counselling? ☐Yes. ☐No
Rate each area of your life
1 – poor 5 - Average 10 – great
Vocational
Familiar
Social
Spiritual
Mental
Physical
Financial
A few questions now to help to determine your unique hierarchy of Values
1. How do you fill your personal space?
Have you ever noticed how things that are really not important to you go into the trash, the attic, or the storage closet? By contrast, you keep the things that are important to you where you can see them, either at home or at work.
What does your life demonstrate through your space? When you look around your home or office, do you see family photos, sports trophies, business awards, books? Do you see beautiful objects, comfortable furniture for friends to sit on, or souvenirs of favorite places you’ve visited? Perhaps your space is full of games, puzzles, DVDs, CDs, or other forms of entertainment. Whatever you see around you is a very strong clue as to what you value most.
What 3 things fill your space?
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2. How do you spend your time?
Here’s something you can count on: people always make time for things that are really important to them and run out of time for things that aren’t. Even though people usually say, “I don’t have time for what really I want to do,” the truth is that they are too busy doing what is truly most important to them. And what they think they want to be doing isn’t really what’s most important. You always find time for things that are really important to you. Somehow, you figure it out. So how do you spend your time? How you spend your time tells you what matters to you most.
In which three ways do you spend your time?
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3. How do you spend your energy?
You always have energy for things that inspire you – the things you value most. You run out of energy for things that don’t. Things that are low among your values drain you; things that are high among your values energize you. In fact, when you are doing something that you value highly, you have more energy at the end of the day than when you started because you’re doing something that you love and are inspired by. So how do you spend your energy – and where do you get your energy?
In which three ways do you spend your energy and where do you feel energized?
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4. How do you spend your money?
Again, you always find money for things that are valuable to you, but you never want to part with your money for things that are not important to you. So your choices about spending money tell you a great deal about what you value most. Now, at this point, you might be noticing some overlap: some similarities between what you fill your space with and how you spend your time, energy, and money. That is healthy. It means that you have already aligned a lot of your values, goals, and daily activities. If you notice a lot of divergence between the answers to these first four questions, you might benefit from bringing your values and goals into deeper alignment.
In which three ways do you spend your money?
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What are 3 things you most like about yourself
What are 3 things you most resent about yourself?
Who do you perceive is pushing your buttons the most?
Who do you resent or despise the most?
Who do you infatuate with or admire the most?
Who do you perceive as ‘hurting’ you?
Who do you perceive as ‘hooking’ you?
Who are you having difficulty loving and would love to love more?
What do you perceive is missing in your life?
What are you currently most stressed and worried about?
Please describe your personal struggles and concerns and the reasons that you are seeking help at this time.
List in order the 3 highest priority things you would change if you could.
What do you feel your most limiting beliefs and blocks are? (Write as much as you like and as best as you can describe what comes up)
Please say a little about what you hope to achieve from our consults.
What else would you like me know?
Thank you for taking the time to fill this out, it will help me make sure we work on the highest priority areas during our time together.
PLEASE CONTINUE TO READ THE INFORMATION BELOW FOR CLIENT CONSENT AND INFORMATION
May I commend you for following your reasoning and/or intuition for reaching out to work with me and this method. Your mind and/or heart have led you to an exceptional opportunity, and it is my commitment to you that you will have a new, balanced and refreshing perspective on the reality of life.
EQUILIBRATE, Transformational Self-Mastery, and the utilisation of The Demartini Method®, was not designed to act as a substitute for the necessary and appropriate treatment of any diagnosed ‘disease’, nor as a replacement of any form of therapy, a substitute for sound legal advice, financial and/or investment advice, nor a substitute for recommended counselling.
Therefore, as a professionally trained facilitator of The Demartini Method® I would love to inform you in advance that I do not treat disease, prescribe drugs, provide therapy or solve legal problems or give financial and/or investment advice. Therefore, I am not here to take the place of your doctor, therapist, lawyer, or financial advisor/accountant/stock broker/realtor.
I am simply here to offer you a new and more profound way of looking at your life and to help you dissolve any internal or external emotional stress and conflict.
I will provide you with leading edge personal transformation methodology that can help you create significant changes in your perceptions and attitude towards, and actions in every area of life.
I am also here to help you learn how to transform any stressful situation you might encounter into a more ordered and meaningful condition or experience. It is my aim to help you experience more moments of gratitude, love, enthusiasm, certainty and presence and help you act from a greater sense of purpose, wisdom, power and poise.
If you were recently or are presently under any form of psychiatric care, psychological therapy, specialized medical supervision, or under the influence of any form of medication, or legal counsel, and financial advice please inform me in advance for special questioning and instructions. Please continue your present care, therapy or counsel and simply incorporate a new paradigm of thinking.
What is the Demartini Method®?
The Demartini Method® is a breakthrough discovery and cutting-edge personal transformation methodology developed by Dr. John Demartini, which results in a new and refreshing paradigm in thinking and feeling. It is a foolproof and effective mean of transforming any form of conflict or stress into grateful states of love and vitality. It is an enlightening procedure, which neutralizes emotional charges and balances mental and physical reactions. It is a reproducible science that enables you to discover the underlying order governing your apparent daily chaos.
As a Demartini Method® facilitator, I will ask you, my client;
A systematic pre-determined series of questions and actions directed towards the objective of bringing you to a state of full consciousness; to your conscious mind the states of presence and certainty and to your heart the feelings of gratitude and love. These questions will assist you in neutralizing your emotional charges and balancing your mental and physical reactions thereby helping you open your heart, clear your mind, expand your awareness, and bring wellness to your body.
I will also ask you, my client, to undergo a continuous thinking process and writing actions repeated over a course of time that results in a resolution of dis-equilibrated perceptions, thereby assisting you in discovering the underlying order governing your apparent daily chaos and empowering you to live a more fulfilled life.
I give Belle Stone, Trained Demartini Facilitator, permission to facilitate The Demartini Method ® on myself for the purpose of reducing stress related concerns so as to enhance my overall well-being and fulfillment of life.
I am inspired to be of service to you
With gratitude and love, Belle