Client Insight Questionnaire

This questionnaire helps me understand your situation before our consultation.

Please answer honestly and in as much detail as possible.

All information is confidential.

First name

Last name

Age

Sex

Male

Female

Occupation

Relationship status

Children (yes/no + ages)

What health condition or symptoms are you experiencing?

When did the symptoms first begin?

Did they start suddenly or gradually?

Have you received a medical diagnosis?

How severe are the symptoms (1–10)?

Timeline (Very Important)

Think back to the months before your symptoms began.

Did any major events occur?

Relationship breakup- Argument or betrayal- Job loss or stress Financial problems- Loss of a loved one or pet- Moving house- Feeling rejected or abandoned- Explain in as much detail as possible.

Current Stress

What currently causes you the most stress? Are there situations in your life where you feel: Trapped- Controlled- Powerless- Rejected- Under pressure- Please Explain.

Relationship Dynamics

How would you describe your relationship with: Mother Father Partner Children Are there any unresolved conflicts in your relationships?

Personality Patterns

Which of the following describe you? People pleaser- Perfectionist- Avoids conflict- Over thinker- Feels responsible for others- Sensitive to criticism..... descibe in detail

Lifestyle

Sleep quality Exercise Diet Alcohol consumption. Please explain in detail

Personal Insight

In your own words: What do you think might be contributing to your situation? What do you feel needs to change in your life?

What was happening in your life right before this condition appeared?

Do you feel stuck in any situation in your life that you cannot easily escape from?

If your body could speak, what do you think it might be trying to tell you?