Constellation Maryland

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Date of Birth *

Participation as: * Select ... Client Support Trainee

Please share your healing request/ area of inquiry? *

Are you experiencing any of the following: * Are you experiencing any of the following: *
 Depression
 Dissociation
 Chronic Stress
 Compulsive Behavior(s)
 Anger
 Compulsive Behavior
 Negative Self Talk
 Shame
 Mood Swings
 Chronic Bad Luck
 Post Traumatic Stress
 Panic or Anxiety Attacks
 Sleep disruptions
 Alcoholism
 Drug Use
 Chronic Illness
 Sense of something missing
 Procrastination
 Paranormal Experience
 Traumatic Loss
 None
 Other

Do you currently have any chronic conditions? *

Have you experienced therapy before? If yes, when was it? For how long? And what Modality? * Was previous therapy helpful? *   yes   no   somewhat  What kind of support are you currently receiving? *  Psychotherapy  Bodywork  Massage  Energywork: reiki, healing touch, etc  Shamanic Work  Acupuncture  Homeopathy  Medical  something else * Have you experienced therapy before? If yes, when was it? For how long? And what Modality? *
Was previous therapy helpful? *   yes   no   somewhat 
What kind of support are you currently receiving? *
 Psychotherapy
 Bodywork
 Massage
 Energywork: reiki, healing touch, etc
 Shamanic Work
 Acupuncture
 Homeopathy
 Medical
 something else

Are you taking any medications? * yes
no

For what purpose do you take medication? *

May I connect with your support team? * yes
no

I agree to hold confidentiality throughout and beyond our meeting time. * Select ... Yes No

I understand that all payment are non-refundable in nature. * Select ... Yes No

Would you like to join our email list? * Select ... Yes No

Is there anything else you wish to share?

What kind of support do you currently receive? * Psychotherapy
Bodywork
Massage
Energywork: reiki, healing touch, etc
Shamanic Work
Acupuncture
Homeopathy
Medical
something else