Full Name (First; Middle; Last): *

Are you named after anyone and if yes, who? *

Your Date of Birth: *

Where were you born? *

What is your heritage/country of origin? *

Where do you currently live? *

List the names and ages of your siblings in birth order, including yourself. *

Are you adopted, and if yes, do you know your birth parents? *

Are any of your siblings adopted? If yes, please name them. *

Are you married? Single? With a partner? *

Have you been married before or had other significant relationships? If so, please list the names of previous significant partners. *

If you have children, please list names and ages in birth order. *

Have you experienced any miscarriages, abortions, stillbirths, or IVF? *

Have you noticed any patterns in your family history? If yes, please explain. *

Please check any of the following which apply to your family history: *
Early deathsTragic events that seem to repeat themselvesRepeated illnessesSignificant dates that events/people shareWarImmigrationImprisonment/locked away against their willAdoptionChildren given awaySecrets that no one in the family discussesAny betrayals or abandonmentSexual abusePhysical abuseAddictions/Alcoholism

Your Session

What do you wish to explore in our session together? What issue(s) do you wish to look at? *

Who do you call upon for comfort, support, and help? This may be a relative, friend, pet, partner, spiritual figure, or anyone you lean on: *