Basic Initial Consultation Questionnaire

Please provide some basic information for the items directly below, in the body of your return email. Items 1 – 8 are for your consideration and are optional in your reply, but please be aware that answering these questions ahead of time will enable me to help you more thoroughly. You can be assured that your answers will be maintained in the strictest professional confidence and will not be shared with anyone, EVER. I would also encourage you to start keeping a food journal of all foods and non foods you consume for the week (7 days) prior to our session.
I look forward to speaking with you!

Just copy and paste this page into an email or word doc to fill out. Use as much space as you need to describe what you are seeking help with.

NAME:
EMAIL:
PHONE: SKYPE:
DATE OF BIRTH:
BEST TIME TO REACH ME:
DESCRIPTION OF MY AREA OF CONCERN:

Are you currently under a doctor’s care? If so, for what complications (dis-ease)? How long have you been experiencing these conditions? Was there a traumatic event that led to your illness? If so, please describe:

Are you taking any prescription drugs or health products? If so, for how long? Please list names of drugs/supplements here:

What have the results been?
Where would you like to be?
What do you feel could be preventing you from achieving total health and wellness?
Would you say you’ve reached a point in your life where you are ready to make changes to achieve optimum health and wellness in your life?

By filling out this form with your digital signature you are indicating that you understand that a Holistic Health Consultation done with Christie Aphrodite, PhD is not a physician/patient relationship with you, you will not be given a medical diagnosis, prescribed any medicine, give psychotherapy or be reimbursable by medical insurance.

You also agree to the cancellation policy and will be responsible for your own choices
in what you choose to do with the information given.

Thank you for taking the time to fill this out! I am honored that you chose me to work with you!


When you have completed this, please email me here so I can get you in the schedule! 🙂

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