Online Hypnotherapy - Treatment Plan Questionnaire This questionnaire will help identify to what extent various areas of your life have imbalances and are in need of work, enabling you and your therapist to use this information for inner healing and realization of your full potential. Please try to answer the question in complete sentences rather than just one or two words. The longer your answers and the more details you give me, the better I can help you. ======================================================= All information is treated in the strictest confidence. ======================================================= Name __________________________________________________________________________ 1. How strongly do you assert yourself in having a) your needs and b) your desires met? (do you err on the side of over or under-assertion?) a) __________________________________________________________________________ __________________________________________________________________________ b) __________________________________________________________________________ __________________________________________________________________________ Has anything angered you lately? __________________________________________________________________________ __________________________________________________________________________ Any problem with the head, such as a headache? __________________________________________________________________________ __________________________________________________________________________ Any vision problem (including the need for corrective lenses or glasses)? __________________________________________________________________________ __________________________________________________________________________ 2. What is the state of your finances? __________________________________________________________________________ __________________________________________________________________________ To what extent do you experience a financial struggle? __________________________________________________________________________ __________________________________________________________________________ Do you have high or low self worth? __________________________________________________________________________ __________________________________________________________________________ Any problems with hearing, the ears, neck or throat? __________________________________________________________________________ __________________________________________________________________________ 3. To what extent is your mental life stimulating or lacking in stimulation? __________________________________________________________________________ __________________________________________________________________________ Any confusion or boredom lately? (assess [over] or [under] stimulation?) __________________________________________________________________________ __________________________________________________________________________ How successful are your communications? __________________________________________________________________________ __________________________________________________________________________ Have you had any misunderstandings lately? __________________________________________________________________________ __________________________________________________________________________ Any problems with sinuses or breathing? __________________________________________________________________________ __________________________________________________________________________ 4. To what extent are you involved with home and family? __________________________________________________________________________ __________________________________________________________________________ Any problems? __________________________________________________________________________ __________________________________________________________________________ Do you feel emotionally secure or insecure? __________________________________________________________________________ __________________________________________________________________________ Any stomach or digestion problems? __________________________________________________________________________ __________________________________________________________________________ 5. Do you have any creative outlets, hobbies? __________________________________________________________________________ __________________________________________________________________________ What forms of entertainment? (assess to what extent creative self-expression is, or is not, happening) __________________________________________________________________________ __________________________________________________________________________ How are your relations with children? __________________________________________________________________________ __________________________________________________________________________ What is your circulation like? __________________________________________________________________________ __________________________________________________________________________ How is your heart? __________________________________________________________________________ __________________________________________________________________________ 6. Regarding practical responsibilities, to what extent do you think you are on top of things or behind a) at work and b) in your personal life? (assess to what extent you are strong or deficient in these areas) a) __________________________________________________________________________ __________________________________________________________________________ b) __________________________________________________________________________ __________________________________________________________________________ Have you had a critical attitude toward a person or situation lately? __________________________________________________________________________ __________________________________________________________________________ Have you had any intestinal or assimilation problems? __________________________________________________________________________ __________________________________________________________________________ 7. Are you in a primary relationship? If so, what is it like? Any problems? (assess any relationship problems, including any related to the lack of a primary relationship) __________________________________________________________________________ __________________________________________________________________________ To what extent is your feeling good about yourself keyed to another person's liking, loving or needing you? __________________________________________________________________________ __________________________________________________________________________ Have you had any aches or pains in your back in recent times? __________________________________________________________________________ __________________________________________________________________________ 8. What is the state of your joint resources with a partner or business? __________________________________________________________________________ __________________________________________________________________________ To what extent is your sex life fulfilling or not fulfilling? __________________________________________________________________________ __________________________________________________________________________ Any problems with elimination or with the pelvic organs? __________________________________________________________________________ __________________________________________________________________________ 9. To what extent do you find your spiritual or philosophical pursuits fulfilling or lacking? __________________________________________________________________________ __________________________________________________________________________ To what extent is there a sense of meaning or, by contrast, emptiness? __________________________________________________________________________ __________________________________________________________________________ What is the condition of the hips and thighs? __________________________________________________________________________ __________________________________________________________________________ 10. To what extent do you experience fulfilment or lack of fulfilment in your current vocation or career? __________________________________________________________________________ __________________________________________________________________________ To what extent do you fear or defer to authority figures as opposed to operating from your own power and authority? __________________________________________________________________________ __________________________________________________________________________ Have you had any problems with teeth or bones? __________________________________________________________________________ __________________________________________________________________________ 11. Do you have many, or few, friends? (Do not include the "occasional" acquaintance). __________________________________________________________________________ __________________________________________________________________________ Are you involved in any groups or organizations? __________________________________________________________________________ __________________________________________________________________________ How do you respond to peer pressure? __________________________________________________________________________ __________________________________________________________________________ Do you conform or rebel? __________________________________________________________________________ __________________________________________________________________________ Any problems with the nervous system, ankles or shins? __________________________________________________________________________ __________________________________________________________________________ 12. In times of stress, do you do anything to withdraw or divert yourself? If so, what? __________________________________________________________________________ __________________________________________________________________________ Any detrimental habits? (assess to what extent you are engaging in escapist activity) __________________________________________________________________________ __________________________________________________________________________ How is your immunity to sickness? __________________________________________________________________________ __________________________________________________________________________ Any problems with the feet? __________________________________________________________________________ __________________________________________________________________________