CONFIDENTIAL QUESTIONNAIRE
For
TRUST IN MIRACLES
TELE - GROUP HEALING
Your answers to some and preferably all of these questions will enable me to determine your mental, emotional and spiritual needs on specific matters, thus allowing me to best serve you as a member of our group healing.
You can trust your comments are safe and completely confidential.
If possible send me a picture as well.
http://www.trustinmiracles.com
Last name: ____________________________ First: _______________________________
Address: __________________________________________________ Apt/Suite: ___________
City: _________________________________ State: __________ Zip Code: _______________
Telephone: (Res.) _________________________________
(Cell)_____________________________
Fax: ________________________ Email: ______________________________________
Date of Birth: ____/____/____ Occupation: _________________________________
1. What is your purpose for being a participant in our group healing tele -seminar?
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2. Present challenges in your life:
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3. Please assign a numerical value (1=slight, 2=moderate, 3=intense)
To describe any degree of fear or difficulty related to the following:
Not fulfilling my true purpose___________ Not in alignment with my true purpose ____
Not knowing my true purpose ______
Feeling stuck _____ Feeling trapped ____ ___ Losing control ____
Success _____ Failure _____ Lack _______ Financially insecurity ____
Inadequacy ____ not deserving _______ Mediocrity ______ Self-sabotage ______
Being visible _____ Being famous _______ Public Speaking _____ Disapproval ___
Being found out ______ The Truth __________ Repeating past mistakes ____
Compromising my personal honor and integrity _____ Not keeping my word _____
Trusting self _____ Trusting others ______ Forgiving self ____ Forgiving others ____
Rejection ___ Abandonment ___ Being alone _____ Being unloved ______
Intimacy _______ Commitment _______ Love _____ Vulnerability _____ Exposure____
Feeling my feelings _____ Expressing myself ______ Communicating authentically ___
Anger with others _______ Anger from others _____ Anger with myself _____
Judgment of others ______ Judgment from others _____ Judging myself _______
Aging _____ Illness _______ Death _______ Purgatory _______ Hell _______
The Unknown ______ My future _______ Being still _____ Being in the NOW ____
God _______ Anger with God _______ Judgment from God _____ Punishment ____
Rejection from God ______ Abandonment from God __________ Trusting God _____
Releasing expectations and agendas ________ Complete Surrender _____ Betrayal ____
Heights _______ Closed spaces _____ Open spaces _____ The Supernatural _____
Flying on an airplane ____ Accidents _____ Worldly affairs ____ Disasters ____
Other: __________________________________________________________________
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4. ADDICTIVE BEHAVIOR: Please indicate present or past
Alcohol: Past _____ Present _______
Marijuana: Past______ Present ______
Cocaine: Past ______ Present _______
Food: Past ____ Present _____
Sugar: Past ___ Present_
Tobacco: Past ____ Present ______
Other recreational drugs: Past _____ Present ______
Medical Drugs: Past ____ Present ______
Narcotics: Past ____ Present ______
Street Drugs: Past _____ Present _____
Sex: Past ____ Present ____
Work: Past ____ Present ______
Gambling: Past ____ Present ______
Television: Past ____ Present ______
Junk food: Past ____ Present ______
Negative thought patterns: Past ____ Present ____
Habits patterns: Past ______ Present _____
Specific people: Past _____ Present _____
Pain: Past _____ Present ______
Feel free to explain: _________________________________________________
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5. EATING DISORDERS:
Over-eating ____ obsessive eating ____ compulsive eating _____ bulimia ____ anorexia __
Under-eating ____
6. Are you or have you ever taken psychiatric drugs? ___ Dates: ______
Attempted Suicide: Year ______ Institutionalized: Dates ______
7. ACCIDENTS: Year and brief explanation __________________________________
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8: SURGERY: Year and brief explanation __________________________________________
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9. Miscarriage(s) _____ Abortion(s) _______
10. What negative thought patterns are you verbally reinforcing? (Assign values of 1, 2 or 3)
I'm not good enough ___ I’m not smart enough ____ I'll NEVER be successful ___
I'm a loser ___ I can’t win _____ Money is the root of all evil ____
I CAN'T! _____ Life is unfair ______ Life is painful. ______
No one understands ______ No one appreciates me _____
I don’t belong ______I don’t fit in _____ There’s something wrong with me _____
I'll NEVER lose weight ____ I’m ALWAYS late __ I can’t think ____
I'll NEVER find true love _______ I’m unlovable _____ I’m unattractive ____
I’m undesirable _____ I’ll ALWAYS be alone ______ My life will be wonderful when___
There's NEVER enough time ____ I’m disorganized _____ I’m lazy _____
Additional: ________________________________________________________________________
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11. Please note a particular topic you would like Renée to address:
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