HEART OF WELL-BEING COACHING
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Welcome Forms to Complete



1. Client Information Form: Please complete the questionnaire below. Use the integrated form if you are at your computer OR print and scan the completed copy and attach to an email back to me at confidential@jillianpedrick.com by return email.
 
2. Office Policies & Consent Form. Please print, read, and sign  the form to indicate that you understand and agree to the policies.  Please scan all pages and attach to an email back to me at this email address.
 
3. Individual Questionnaire.  Please complete this form and return to me before Monday of your first session. Either use the confidential online questionnaire right here on this page OR print, complete, scan and email the Intake Questionnaire back to me.

IMPORTANT NOTE: All forms must be completed and in my hands prior to the MONDAY morning of the week of our first session.


jlp_distance_office_policy_2016_v1.pdf
File Size: 311 kb
File Type: pdf
Download File

jlp_client_quaire_2016_v1.pdf
File Size: 424 kb
File Type: pdf
Download File

jlp_client_information_form_2016_v1.pdf
File Size: 727 kb
File Type: pdf
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PLEASE ALSO NOTE: ALL THESE FORMS CAN BE EMAILED TO YOU IF YOU HAVE TROUBLE ON THIS SITE.
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 Intake Questionnaire - PART A

    Please take your time when answering the questions that follow. Your work will be enhanced when you complete the questions thoughtfully and honestly. Feel free to attach additional pages if necessary. Please give as complete an answer as you can. 1. Presenting Issue. What is the problem that led you to decide to come to therapy, or this workshop? How long has this situation been a problem for you? What else was going on for you at this time or what else were you doing at the time this problem/situation began?
    2. Previous Status. What was your experience with this before this problem started? Have you ever had panic attacks, depression, completing things in your life before even in elementary school or high school?
    3. Relationships. Are you married or in a long-term relationship? For how long? If so, how would you describe this relationship? How did you meet? Does he/she know that you are here and how do they feel about it? How supportive is your partner in your life? Who was your previous long-term relationship? How would you have described that person? Who broke up? How was that for you?
    15. Therapy. Have you done any counselling in the past? If so, what was the experience like for you? What were your ‘take-aways’ about yourself/therapy/other from that process?
Submit Your Answers

    INTAKE QUESTIONNAIRE - PART B

    5. Friendships. Who do you trust? Who supports you? Do you have any best friends or any friends? What has your experience of relationship been? Are you loyal/betrayed/ let down?
    6. Social Life. What do you do for fun/ With who? How engaged are you in your life or is it someone else’s life that you are engaged to?
    7. Work. What kind of work do you do? Do you enjoy it? How did you choose this? What career visions do you have for yourself? History of work – how does it usually end for you?
    8. Finances. Is money an issue for you in terms of creating conflict or stress? Is it an addiction?
    9. Health. How is your health in general? Do you have regular headaches, back aches, stomach aches, etc.? Have you had major surgeries, health challenges or accidents?
Submit Your Answers

Locations

Suite 312, 2233 Burrard Street
Vancouver, BC, V6J 3H9
OR

Visit at any one of our locations in the Lower Mainland.

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  • Home
  • HEALING THE HEART
  • MEET SUSAN
  • WHAT CLIENTS SAY
  • IMAGINE BEING TRULY HAPPY
  • Holographic Memory Resolution
  • Healing the Heart Method
  • EVENTS & WORKSHOPS
    • Tech Magic VIP Day
    • Business Success for Therapists
    • MAY THE FORCE BE WITH YOU
  • EMF Protection
  • Contact
  • Product
  • Product
  • New Page