If you decide to come to for one to one sessions at the Norfolk Clinic please print off the questions below and answer as many as possible before the session as this will help in designing the best possible individual programme for you.
All information you give is confidential
Initial questions form
Name
Address 
Telephone
1 Please describe key aspects of your present issue/problem/symptoms
2 On a scale of 1 to 10 (10 is high), rate the degree of problem this is causing in your life right now.
3 Please describe times and situations when is this problem at it's worst
4 Please describe times and situation when you are least affected
5 If you pretend that you knew why you had this problem, what would would you say?
6 What would you say have been some of your greatest accomplishments to date? Both personally and those that might be recognised by others.
7 What is the hardest thing in your life so far that you have had to overcome?
8 Who are or have been your major role models and in what ways have they affected you?
9 Is there anything from your childhood that you think could relate to the issue?
10 If you had a magic wand to make a wish for anything you wanted/needed, what would you wish for? (must be just for you ie not something like world peace!)
11 What major transitions have you had in the past two years? (Entering or approaching a new decade, a new relationship, a new job, a new role, a new residence,a bereivement, change in children’s ages/stages, etc?)
12 What are the three biggest changes you want to make in your life in the next three months?
13 What are the three biggest changes you want to make in your life over the next three years?
14 Which of those do you most want to achieve and why?
15 What do you feel is stopping you from achieving this?
16 List the five adjectives that best describe your strengths (you at your best).
17 List the five adjectives that most describe the things you struggle with about yourself.
18 What are your 3 major concerns/fears about yourself?
19 What are your 3 major concerns/fears about life?
20 What really motivates you?
21 What really demotivates you?
22 Looking at the past six months of your life, do you like the direction your life is moving in? If not, what specifically do you not like?
23 On a scale of 1 to 10 (10 is high), rate the amount of stress in your life right now.
24 What are the things that are causing you the most stress at the moment?
25 List the five things that you are tolerating or putting up with in your life at the present. (Example: Information you can’t find, clutter, unsupportive friends, job satisfaction, broken or old equipment, weeds in your garden, etc.)
26 What do you enjoy doing, your hobbies/interests?
27 Please write a vivid statement about how you would like to be remembered after the end of your life.
28 Please write in bullet point/note form a brief life history of significant events both positive and negative up to the present day.