dynamic emotional integration® consultation 

In preparation for your Dynamic Emotional Integration® consultation, please fill out this questionnaire.

As you answer these questions treat them as a snapshot of your current situation, behavior, skills, challenges, and resources, so that we can focus clearly on your present-day situation.

The information you provide below will help me understand your current emotional strengths and challenges, the current social-emotional situations you're dealing with, and the supportive resources you have in your life.

All of your information-here and in your consultation-will remain confidential.

Name *
Name
Address
Address
There are times I like to send things in the mail. If you wish to not receive please feel free to not include
Phone *
Phone
Just in case we have internet connectivity challenges!
About your situation
I have current concerns about (check any that apply and explain below): *
About You
I am comfortable speaking up for myself, even during conflicts: *
I feel heard and respected in my interpersonal relationships: *
I take good care of myself, and I can say no to demands on my personal time: *
I can make clear distinctions between my own emotions and the emotions of others: *
I am able to choose whether I feel other people's emotions or not: *
I tend to remain calm and focused in emergencies: *
When I think of large projects, or places I have to get to at a specific time, I feel pretty relaxed: *
I make time to laugh and have fun, and I look forward to the future: *
I tend to trust that new situations and new relationships are going to work out: *
I'm able to change my mind when I discover better information and new ideas *
I can relax and calm myself down, and I have reliable self-soothing skills: *
I'm comfortable talking about my talents and my achievements: *
I can move on from situations that aren't healthy or really can't work: *
I have a fairly easy time changing problem behaviors when I become aware of them: *
About your support system
I have supportive and nurturing relationships with (check all that apply): *
Artistic Expression *
Self-Care and Personal Growth activities (please check all that apply): *
I have support in my working life from (check all that apply): *
About this consultation
I understand that a Dynamic Emotional Integration® consultation is not a substitute for psychotherapy or medical advice, and I take full responsibility for alerting my healthcare and mental health practitioners about any changes resulting from this consultation that may affect my current treatment (if any) *
By checking the box below you are agreeing
Date *
Date