Client Form

Below are the instructions for completing your form.

Filling in your form is optional and will assist you getting profound results more rapidly. The instructions below will make it easier to complete your form.  Feel free to save time by filling in the form and emailing it back before your appointment. The instructions below will make it easier.

Page 1 is straight forward.
The following pages we usually fill out with you. It will save you time if you can fill some of these pages in yourself beforehand.

Page 2 each row represents a different goal. This will assist us to focus on what’s most important to you.
Eg1. What you want – “Have a happy, loving relationship/marriage” – “Earn $_____ p/a doing what I enjoy” – “Achieve and maintain my ideal weight of __ kg.” – “Be a non smoker”
How you feel now without it. Frustrated, sad, angry…. How will you feel when you have it – loved, appreciated, worthy…..

Page 3 is an emotional life summary up to age 21. (Research shows that the programming we receive in our early years can dictate our emotional patterns for life.)
Include your age at the time, a brief description of events and how you felt. Remember there is no right or wrong, it just is.
If you were told about your birth include that as well and anything else that you can remember.
If you don’t remember how you felt just imagine how someone else would have felt in the same situation.

Below are some typical examples.

Born premature or forceps delivery not sure how I felt probably lonely & afraid.
2 yrs old first day at child care, cried a lot felt sad and anxious.
2 yrs old my baby sister was born, felt jealous angry & unloved.
4 yrs old migrated to Australia missed my friends & favourite auntie felt lonely and angry at parents.
5-15 yrs Dad was very authoritarian and often hit me. Felt stupid, guilty, anxious and angry.
8-12 yrs bullied at school felt fear, angry and helpless.
11 yrs old Fell out of a tree broke my right leg.
12 yrs. Mum bought me a second hand uniform for first day at high school. Felt poor, not good enough.
14yrs. My dog Freckles died, (hit by a car) I blamed myself felt guilty, sad & angry.
15yrs. My girlfriend/boyfriend dumped me and went out with my best friend. Felt hurt and sad.
17yrs. Parents separated & injured in car accident (leg knee & head injuries). Sadness, fear & anger
These are only examples. Remember to keep it simple and brief.
You may also note any family patterns or traits like “All of the women in our family are overweight.” Or “My father and grandfather both had heart attacks by the time they were 55 years old.”
You may also draw a picture which includes a House, a tree, a body of water and a snake. Use a single A4 page, pen or pencil. Allow about 4-5 minutes (we’re not assessing artistic ability, Just imagine that you are a 6 year old child drawing a picture.)

*Cancellations Policy:- We run a standby system, If you need to change your appointment time please notify us by telephone 03 9722 2678 at least 48 hours prior to your appointment so that we can give your place to someone else. Cancellations less than 48 hours before an appointment may incur a $200 Cancellation fee.

Your investment is $200 per hour or $350 per 2 hours.
Concession rates apply if your income falls below $70,000 per annum. Concession rates are $150 per hour or $250 per 2 hours.

Coaching is given via telephone, Skype or face to face.

If you have any questions then please call Russell on 03 9722 2678.