Personal
Name *
Name
Phone *
Phone
Birth Date
Birth Date
Birth Time (No 'second' needed)
Birth Time (No 'second' needed)
If so, please explain.
Health
i.e why are you here today? :)
Please include anything physical, emotional, mental, spiritual.
Please describe.
If so, please describe and list any medical tests, diagnoses, surgeries, treatments you have received.
If yes, please list and for how long.
Please explain the possible sources (ie. work, relationships, etc)
If so, what kind and how often?
How many hours? Are they restful? If not, please explain.
What do you do to relax? Is there a routine to this?
SUCCURRO Fellows only
Bullet points for each of these questions will do!
What might you hope to address, achieve, consider closely? Personally, and within a group.
What do you do, how often? How does it currently relate to your general health and wellbeing?