Client Interview Form-2

Pearl Therapy Preliminary Information Form-2

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HOLISTIC SUBCONSCIOUS APPLICATIONS

CLIENT PRELIMINARY INFORMATION FORM

The first and most important step in solving a problem;

-Determining the main causes of the problem in every aspect and completely ve

-It begins with knowing the client in every aspect.

That's why we want to get to know you better so we can help you.

Although some questions may seem irrelevant or unimportant to you, it is very important for the efficiency and speed of our work together that you answer each question completely, in detail and honestly.

All your information will be kept confidential.

Filling out the forms will take approximately 45 minutes.

Residential

Name and surname

Middle name

Surname

Gender

Female
Male

Residential

Official Date of Birth

City of Birth

Your Mobile Phone Number

2. Your Mobile Phone Number

E-mail

What is your current job?

Actual Date of Birth If Different

Original Homeland

Marital status

The married
Single (Unmarried)
Widow (Death)
Divorced

Address

Address Line 1

Address Line 2

City

State/Territory

Post code

Country

What is the main purpose of your appointment and the main problem you want to get rid of? (Write in detail with all side effects and symptoms)

Your Main Profession

Last University / Department / Year You Graduated

Other University / Department / Year You Graduated

High School / Department / Year / City you graduated from

Secondary School / Year / City You Graduated

Primary School / Year / City You Graduated

Who do you live with in the same house?

If You Have a Health Problem-1 and Its Level

If You Have a Health Problem-2 and Its Level

Name and age of your first child, if any (including miscarriage, abortion, or death, if any)

Are Your Mom and Dad Together?

Together
They divorced
Separated Due to Death

Residential

Is Your Mother Alive?

Alive
He passed away

Your Mother's Profession

The Last School Your Mother Completed

Your Mother's Previous Occupation

How Many Years Did Your Father and Mother Marry?

Is Your Father Alive?

Alive
He passed away

Layout (copy)

Your Father's Profession

The Last School Your Father Completed

Your Father's Previous Profession

How Many Years Did Your Mother and Father Get Married?

Where or from whom did you get your name? (A relative or acquaintance's name?)

What Your Mother Experienced During Her Pregnancy (Sad Events, Death, Bankruptcy, Loss, Separation, etc.)

Write What You Know About Your Birth (Unwanted pregnancy, difficult birth, premature birth, cesarean section, etc.)

Write down your siblings' information, including abortions and miscarriages.

1. Your Sibling's Name

1. Your Sibling's Age

If there is any abandonment in your family, please write.

If there is a murder(s) in your family, please write.

If there is a significant negative event(s) that has happened in your family, please write it down.

If there are any topics that are avoided in your family, please write them down. (Death, bankruptcy, accident, loss, suicide, illness, abuse, etc.)

If you have given permission to people to share information with us about your condition and changes in you;

Residential

Name and surname

Surname

Closeness

Phone

Layout (copy)

Name and surname

Surname

Closeness

Phone

What are the issues and situations that you find particularly difficult in your daily life?

Are you getting enough sun and sunlight?

How often do you consume natural vinegar?

How often do you consume natural pickles?

How often do you consume homemade yogurt?

Do you eat regularly, naturally and healthy?

What are your habits of doing sports and moving?

What's your sleep schedule? What time do you go to sleep and wake up? Does it seem enough to you?

If so, when did you first use drugs? Which drugs do you use and how often?

If you smoked, when did you smoke your first cigarette?

How often do you smoke?

If so, when was your first drink of alcohol?

How often do you drink alcohol?

If so, when did you place your first bet?

How often you gamble

What kind of gambling do you do?

Do you have a vegan, vegetarian or similar lifestyle?

Do you believe in a creator?

Do you believe in life after death?

If so, what is your religion and sect?

How do you define yourself in terms of faith?

If you have allergies, what are they? Since when? At what level?

What are the positive and negative aspects of your life that are similar to your mother?

What are the positive and negative aspects of your life that are similar to your father?

Besides your mother and father, who in your extended family do you resemble, and what characteristics do you have?

Who are the people you say to, “I HAVE SOME FEELINGS AND THOUGHTS INSIDE ME AND I WANT TO TELL THEM TO HER, BUT I WON’T DO THAT BECAUSE I MIGHT HURT HER, OR CAUSE PROBLEM, OR BECAUSE I CANNOT SEE HER ANYMORE”?

What Are You Ready to Change in Your Life?

When and where do you feel your worst while going about your daily life? And what emotion do you feel? (Anger, Fear, Shame, Sadness, Disgust, Anxiety, Surprise, etc.)

Is there an event/experience that you can't tell anyone about, that only you know, and that you keep like a secret that you say "I could never tell anyone"?

Do you have a dream that you see often?

(Please Complete the Sentence) The thing/things I want to realize most in this life is…

(Complete the sentence please) The feeling that I want to feel to the fullest / that I miss is……

To mutually evaluate the effectiveness of our collaborative work, can you visualize yourself "achieving the internal and external change you aimed for?" Share what you visualize.

Apart from these, is there anything else you would like to add that you think would be good to know for your own good and benefit?

Is there anything you are sensitive about that you would like the EFT and Hypnosis Specialist to pay attention to or absolutely avoid?

Have you ever received any therapy, psychiatric diagnosis, or support through EFT, HYPNOSIS, Breathwork, Bioenergy, or other methods? If so, please provide detailed information. (When? How long? From whom? What kind of session was performed? What did you feel?)

What are your expectations / goals regarding this work we will do together?

When did this problem start? What were your experiences before this problem started?

What factors increase or decrease the problem you are experiencing?

Is there any other person who has an influence on the problem you are experiencing? If so, please briefly explain.

What is the second problem you want to get rid of? (Write in detail with all side effects and symptoms)

2. When did your problem start? What were you experiencing before this problem started?

2. Is there any other person's influence on your problem? If so, please briefly explain.

What are the factors that increase or decrease the second problem you experience?

Apart from these problems, what other problems do you have that you think are related or unrelated to this problem? (insomnia, anger, itching, sweating, nightmares, stomach problems, intestinal problems, skin problems, phobias, tics, habits, or anything else like these)

IN ORDER TO GET RID OF YOUR PROBLEMS IN A HEALTHY WAY DURING THE THERAPY PROCESS; Will you do the simple tasks given by the specialist, which will take 15 minutes a day and penetrate into your subconscious with your practice?

Will you listen to some audiobooks and documentaries that will be sent to you to positively influence your subconscious?

Upload a photo of yourself showing your face

Click or drag the file into this area to upload.

Upload your past blood and urine test results.

Click or drag the file into this area to upload.

We congratulate and thank you for carefully filling out and sending this information, which will contribute to YOU in our work together.

If you have read the information above and agree to this form being sent to Pearl Therapy, please submit the form by checking the box.

Yes, I have read the above information, and I agree to send this form to Pearl Therapy.

August 15, 2024 Pearl

HOLISTIC SUBCONSCIOUS APPLICATIONS

CLIENT PRELIMINARY INFORMATION FORM

The first and most important step in solving a problem;

-Determining the main causes of the problem in every aspect and completely ve

-It begins with knowing the client in every aspect.

That's why we want to get to know you better so we can help you.

Although some questions may seem irrelevant or unimportant to you, it is very important for the efficiency and speed of our work together that you answer each question completely, in detail and honestly.

All your information will be kept confidential.

Filling out the forms will take approximately 45 minutes.

Write down your siblings' information, including abortions and miscarriages.

We congratulate and thank you for carefully filling out and sending this information, which will contribute to YOU in our work together.

Note: This form is private to Pearl Therapy and sharing it with others is prohibited.

After filling out the form above, please click the Send button and send it.

Click here to move on to the next form.

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