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First Name
Last Name
Mailing Address
Apt#
City
State:
Zip:
Country:
Email:
Telephone:
Date of Birth:
Job Title:
Please Name Two Supportive Figures in Your Life
Name:
Contact:
Name:
Contact:
Contact incase of emergency
Name:
Contact:
Gender:
Male
Female
Non-Binary
What is your relationship status?
single
in a relationship
married
domestic partner
separated
divorced
widowed
not sure
Have you ever been in therapy or counseling before?
No
Yes
Are you currently in therapy or counseling?
No
Yes
How long have you been in counseling?
less than a year
1-2 years
2-5 years
5-10 years
10+ 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?
ADHD
Depressive Disorder
Anxiety Disorder
PTSD
OCD
Other:
Other:
Explain:
Have you been diagnosed by a Psychiatrist?
No
Yes
How long have you been practicing The Completion Process?
Never
I’ve done it a couple times
Less than 6 months
6 months - 1 year
1-2 years
Over 2 years
What is your experience with the Completion Process?
How familiar are you with Teal Swan’s Work?
Not at all
Somewhat familiar
Very Familiar
Explain:
How would you rate your current physical health?
Good
Fair
Poor
Explain:
How would you rate your sleeping habits?
Good
Fair
Poor
Explain:
How would you rate your current eating habits?
Good
Fair
Poor
Explain:
How would you rate your current financial status?
Good
Fair
Poor
Explain:
Have or are you currently experiencing depressive symptoms?
No
Yes
Explain:
Are you currently experiencing overwhelming sadness, grief or depression?
Not at all
Several days
More than half the days
Nearly everyday
Explain:
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 all
Several days
More than half the days
Nearly everyday
Explain:
Over the Past two weeks have you been bothered by any of the following problems?
Feeling down, depression or hopeless
Not at all
Several days
More than half the days
Nearly everyday
Explain:
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 all
Several days
More than half the days
Nearly everyday
Explain:
Over the Past two weeks have you been bothered by any of the following problems?
Feeling tired or having little energy
Not at all
Several days
More than half the days
Nearly everyday
Explain:
Over the Past two weeks have you been bothered by any of the following problems?
Feeling tired or having little energy
Not at all
Several days
More than half the days
Nearly everyday
Explain:
Over the Past two weeks have you been bothered by any of the following problems?
Poor appetite or overeating
Not at all
Several days
More than half the days
Nearly everyday
Explain:
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 all
Several days
More than half the days
Nearly everyday
Explain:
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 all
Several days
More than half the days
Nearly everyday
Explain:
Are you currently experiencing anxiety, panic attacks or have any phobias?
Yes
No
Explain:
Are you currently experiencing any chronic pain?
Yes
No
Explain:
Are you currently having suicidal thoughts or have you had suicidal thoughts?
Yes
No
Explain:
Do you suffer from the feeling of isolation?
Yes
No
Explain:
Do you currently feel isolated in life?
Yes
No
Explain:
Do you have any problems or worry about intimacy?
Yes
No
Explain:
Please name all the medications you are currently taking
How often do you drink alcohol?
Never
Infrequently
Monthly
Weekly
Daily
Do you now or have you ever experienced in the past problems related to alcohol or drugs?
Yes
No
Explain:
How supportive do you consider the people in your current living situation
Very Supportive
Somewhat Supportive
Not Very Supportive
Completely Unsupportive
Explain:
Describe your living situation
Who Referred You to The Completion Process?
I agree to process my personal data