Questionnaire

Your Name (required)

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Client name - (first and last name / if different from above)

Home Phone

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Preferred method of contact?
 Email Phone Call Text Message

Which type of visit do you prefer?
 Phone Consultation Office Appointment Home Visit

Preferred Date to Contact
 Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Preferred Time to Call
 Morning Afternoon Evening

Subject

Things you would like to improve for yourself or a family member - Please check all that apply, type in your contact information and then click Send.

 Patience  Immune System  Coordination   Balance   Spelling   Reading Comprehension   Addition, Subtraction, Multiplication & Division   Self Love   Self Esteem   Self Assurance   Self Respect   Self Worth   Self Confidence   Performance under Pressure   Sensitivity   Creativity  Thoughtfulness   Thoroughness   Self Motivation   Motivation of Others   Social Interaction Skills   Tolerance   Self Awareness   Temperment   Determination   Starting Tasks Ability   Finishing Tasks Ability   Focus on task at hand   See the Big Picture more clearly   Kindness   Sincerity   Honesty   Overcome Fears or Phobias   Write more Legibly   Enjoy Reading more   Be free of Eye Strain   Be free of Pain   Be free of a dependency   Be free of regret   Be free of Doubt   Self Control   Logical Thinking   Intuition   Openness to others   Openness to divine guidance   Vision   Hearing   Sense of Smell   Sense of Taste   Sense of Touch   Spinal Alignment   Be free of Allergies   Time Management   Overcome shyness   Following Directions   Remembering names   Giving directions and instructions   Remembering right from left   Differentiating colors   Overcome Headaches or Migraines   Staying Alert   Maintaining Energy level   Overcoming Letter/number reversals   Organizational Skills   Overcome Speech Difficulties   Overcome TMJ/Orthodontics issues   Recover from Head Traumas/Car Accidents   Get help dealing with Autism   Other issue - plaease check and explain below

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