No.15 Arthur Street, Newton Stewart, DG8 6DE :: tel 01671 402 523 :: e-mail TherapywithSusan@aol.com
Questionnaire for Applicants to the
Toning for Health Course
If you were considering joining us, Anna would like to get to know you.
Please cut and paste this Questionnaire into an email and complete. Write "Questionnaire" in the Subject Field. Complete the questions and email to Anna Rewilak, Completing this questionnaire does not constitute a commitment of any kind; it’s simply an opportunity for you and Anna to get acquainted.
Your answers to these questions are completely confidential. You are not required to answer all the questions.
Primary Phone Number:
Skype name (if available):
Website (if applicable):
Date of Birth:
How did you find out about the Toning for Health course?
What do you want most to change or to evolve about yourself?
Level of Formal Education
Special training, workshops and apprenticeships in healing and related areas (if any)
What experience have you had in healing other people? (Any kind)
What would you like Anna to know about you?
Name and tell about one person who has had a profound influence on you, and why.
Are you currently in counselling or therapy or under the care of a psychiatrist for any condition? Please explain
If you are taking drugs (of any kind) for depression or mental conditions or physical conditions, please elaborate
Do you use recreational drugs or alcohol or cigarettes or caffeine frequently? Please elaborate
Are you currently under the care of a physician for any chronic conditions? Please explain.
Ask Anna good question
OPTIONAL QUESTIONS If you would like to go deeper, feel free to answer any of these questions:
What do you value most in life?
Do you have any kind of spiritual practice? Please describe.
What do you do when you are under a lot of stress?
What do you do when you feel angry?
Do you see, hear, or feel energies or have experiences that are unusual? Please elaborate
Please know that at No.15 we try to create an atmosphere of unconditional love and acceptance. Anyone who attends these workshops is asked to leave their judgments behind. If this is difficult for you to do, that’s okay, as long as you see it as a challenge and are willing to be honest and work on changing your attitudes (toward yourself and others).
Thank you for taking the time to do this