Name
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First Name
Last Name
Email Address
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Address
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Address 1
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City
State/Province
Zip/Postal Code
Country
Phone
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I have current concerns about (check any that apply and explain below):
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If you checked anything above please explain here:
I am comfortable speaking up for myself, even during conflicts:
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I feel heard and respected in my interpersonal relationships:
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I take good care of myself, and I can say no to demands on my personal time:
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I can make clear distinctions between my own emotions and the emotions of others:
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I am able to choose whether I feel other people's emotions or not:
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I tend to remain calm and focused in emergencies:
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When I think of large projects, or places I have to get to at a specific time, I feel pretty relaxed:
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I make time to laugh and have fun, and I look forward to the future:
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I tend to trust that new situations and new relationships are going to work out:
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I'm able to change my mind when I discover better information and new ideas
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I can relax and calm myself down, and I have reliable self-soothing skills:
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I'm comfortable talking about my talents and my achievements:
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I can move on from situations that aren't healthy or really can't work:
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I have a fairly easy time changing problem behaviors when I become aware of them:
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I have supportive and nurturing relationships with (check all that apply):
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If you checked other please tell me more:
Artistic Expression
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If you checked other please tell me more:
Self-Care and Personal Growth activities (please check all that apply):
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If you checked other please tell me more:
I have support in my working life from (check all that apply):
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If you checked other please tell me more:
What specific issues or concerns do you want to focus upon?
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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)
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By checking the box below you are agreeing
Date
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