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SMGI® Questionnaire ~ Part I
Marital Status
May we leave a message/text?
May we leave a message/text?
Are you currently taking any prescription medication?
Are you currently taking any prescription psychiatric medication?
General Health and Mental Health Information
1. How would you rate your current physical health? (please check box)
2. How would you rate your current sleeping habits? (please check box)
5. Are you currently experiencing overwhelming sadness, grief, or depression?
6. Are you currently experiencing anxiety, panic attacks, or have any phobias?
7. Are you currently experiencing any chronic pain?
8. Do you drink alcohol more than once a week?
9. How often do you engage in recreational drug use?
10. Are you currently in a romantic relationship?
Family Mental Health Information

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided, (ie., father, grandmother, uncle, etc.):

Alcohol/Substance Abse
Domestic Violence
Eating Disorders
Obsessive Compulsive Disorder
Suicide Attempts
Additional Information
1. Are you currently employed?
2. Do you have a religious or spiritual practice?

Thanks for Submitting Part 1 of the Questionnaire.


Part 2: Getting To Know You

SMGI® Questionnaire ~ Part II
Getting To Know You

3. On a scale of 0 - 10 (10=best) how would you rate your self-confidence?

Your Outer Confidence
Your Inner Confidence
Your Childhood
Your Teenage Years
Your Current Situation
On a scale from 0-10 (10 = highest), how important is accomplishing the above matter to you now?
13. Have you used hypnosis or guided imagery before?
14. Have you been diagnosed as dyslexic?

Thank you! I'm looking forward to our first session together.

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