Alternative Therapy Questionnaire
© 2003 Jaclyn Henderson, RC (Registered Counselor WA No. RC28265) All Rights Reserved Complete the bottom-half just AFTER. Name______________________________ Therapy___________________________ Date ___/___/___ Date of Birth: ___/___/___ Marital Status: _________________________ Sex: M F
llness or Condition? YES NO If YES, give name(s) & duration(s)___________________________ ________________________________________________________________________________ On a scale of 1 – 10, please indicate how you feel right now:
Physically Tense ________ Relaxed
Emotionally Tense ________ Relaxed
Mentally Sluggish ________ Alert
Fragmented ________ Whole
Non-Accepting ________ Accepting
Odds with Life ________ One with Life
Out-of-Touch ________ In Touch
Extreme ________ Gentle
Anxious ________ Tranquil
I anticipate a positive therapeutic result from my session today. YES NO
Does Jaclyn Henderson, RC have your permission to alter names & publish your findings? Y / N
If YES, Sign / Date and send copy to Jaclyn. __________________________________/_______________ P. O. Box 1112 Port Orchard, WA 98366-1112
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Post-Alternative Therapy Questionnaire On a scale of 1 – 10, please check how you feel RIGHT NOW::
Physically Tense ________ Relaxed
Emotionally Tense ________ Relaxed
Mentally Sluggish ________ Alert
Fragmented ________ Whole
Non-Accepting ________ Accepting
Odds with Life ________ One with Life
Out-of-Touch ________ In Touch
Extreme ________ Gentle
Anxious ________ Tranquil
Overall has this session helped you today? YES NO
Do you feel that your session today has helped to heal you? YES NO
Feel as Before _________ Better
(c) 2003 Jaclyn Henderson, RC (Registered Updated for ease in printing 10/19/03