First Name
Last Name
Mailing Address
Apt#
City
State:
Zip:
Country:
Email:
Telephone:
Date of Birth:
Job Title:
Name:
Contact:
Gender: MaleFemaleNon-Binary
What is your relationship status? singlein a relationshipmarrieddomestic partnerseparateddivorcedwidowednot sure
Have you ever been in therapy or counseling before? NoYes
Are you currently in therapy or counseling? NoYes
How long have you been in counseling? less than a year1-2 years2-5 years5-10 years10+ years
What kind of Therapies or Counseling have you tried?
What is your experience with Therapy or Counseling?
Have you been diagnosed by a Psychiatrist? ADHDDepressive DisorderAnxiety DisorderPTSDOCD
Other:
Explain:
Have you been diagnosed by a Psychiatrist? NoYes
How long have you been practicing The Completion Process? NeverI’ve done it a couple timesLess than 6 months6 months - 1 year1-2 yearsOver 2 years
What is your experience with the Completion Process?
How familiar are you with Teal Swan’s Work? Not at allSomewhat familiarVery Familiar
How would you rate your current physical health? GoodFairPoor
How would you rate your sleeping habits? GoodFairPoor
How would you rate your current eating habits? GoodFairPoor
How would you rate your current financial status? GoodFairPoor
Have or are you currently experiencing depressive symptoms? NoYes
Are you currently experiencing overwhelming sadness, grief or depression? Not at allSeveral daysMore than half the daysNearly everyday
Over the Past two weeks have you been bothered by any of the following problems? Little to no interest or pleasure in doing things Not at allSeveral daysMore than half the daysNearly everyday
Over the Past two weeks have you been bothered by any of the following problems? Feeling down, depression or hopeless Not at allSeveral daysMore than half the daysNearly everyday
Over the Past two weeks have you been bothered by any of the following problems? Trouble falling asleep, staying asleep or sleeping too much Not at allSeveral daysMore than half the daysNearly everyday
Over the Past two weeks have you been bothered by any of the following problems? Feeling tired or having little energy Not at allSeveral daysMore than half the daysNearly everyday
Over the Past two weeks have you been bothered by any of the following problems? Poor appetite or overeating Not at allSeveral daysMore than half the daysNearly everyday
Over the Past two weeks have you been bothered by any of the following problems? Feeling bad about yourself. Feeling that you are a failure or have let yourself or your family down. Not at allSeveral daysMore than half the daysNearly everyday
Over the Past two weeks have you been bothered by any of the following problems? Trouble concentrating on things such as reading or watching videos Not at allSeveral daysMore than half the daysNearly everyday
Are you currently experiencing anxiety, panic attacks or have any phobias? YesNo
Are you currently experiencing any chronic pain? YesNo
Are you currently having suicidal thoughts or have you had suicidal thoughts? YesNo
Do you suffer from the feeling of isolation? YesNo
Do you currently feel isolated in life? YesNo
Do you have any problems or worry about intimacy? YesNo
Please name all the medications you are currently taking
How often do you drink alcohol? NeverInfrequentlyMonthlyWeeklyDaily
Do you now or have you ever experienced in the past problems related to alcohol or drugs? YesNo
How supportive do you consider the people in your current living situation Very SupportiveSomewhat SupportiveNot Very SupportiveCompletely Unsupportive
Describe your living situation
Who Referred You to The Completion Process?
I agree to process my personal data