110 Haverhill Road, Suite 517 | Amesbury, MA 01913
978-337-7753
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Karen LoGiudice
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I am looking forward to working with you! Please take a moment to fill out the questionnaire below before we get started.
Getting Started/Getting to know you...
In preparation for our first meeting, it would be really helpful for you to fill out the following questions. This is between you and me, and we will use this to customize the work we do together. So, please be as open and honest as possible. :)
I am looking forward to meeting with you!
The Easy Stuff...
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Please provide your contact info.
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First
Last
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Phone Number
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Now let's get down to business...
Which of the following best describes the reason you are coming?
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Feeling Stuck
Feeling Fearful
Anxiety/Depression
Want more control of my life and future
Want to explore the Law of Attraction
Want to open up Spiritually
Experience recurring negative cycles in life
Want more self-confidence
Need new tools to deal with life situations
Seeking my life's purpose
Need to forgive myself or others
Difficulty letting go of the past
Need emotional healing from past trauma
Other
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On a scale of 1-10, how familiar are you with the Law of Attraction (1=What is that?!?; 10=It's no Secret to me!)
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Do you believe you have control over your own thoughts?
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No
Yes
Most of the time
Not sure
My thoughts are on autopilot
I am very aware of what I am thinking most of the time
I easily get "lost in my thoughts" and find it challenging to "get myself back"
I can easily shift/change my thoughts at will
Please choose the one that best suits you.
Are you or have you ever suspected that you are: (check all that apply)
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Dyslexic, ADD/ADHD, or have other learning challenge
Autistic (including Aspergers/ASDs)
Kinaesthetic or Visual Learner
Empathic
Intuitive
HSP (Highly Sensitive Person)
Psychic/Medium
Do you meditate?
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Yes, frequently
No, never
Sometimes
I have tried, but find it very difficult
What are your biggest worries right now? (check all that apply)
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Finances
Confidence
Feeling unworthy
Relationship issues
Not on my life's path
Technology
Weight/Health
My Business
Putting myself "out there"
Too much chaos
Fearful of current events
I don't really have any worries, but want to work on myself
What kind of coaching/therapies have you tried in the past? (check all that apply)
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Traditional talk therapy
Self-help books/programs
Personal self-help coaching/life coaching
Meditation/Guided Meditations
Yoga/Qi gong/Martial Arts
Reiki/Acupuncture/other energy work
Positive Affirmations
EFT/Tapping
IFS (Internal Family Systems)
Cognitive Behavioral Therapy
Alternative/Metaphysical therapies (please specify in "Other")
None
Other
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Do you feel that you need help with focus, centering, and/or grounding?
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Yes!!
Sure, why not?
No, I'm good!
On a scale of 1-10, where do your typical thoughts resonate? (1=Extremely negative/fearful; 10=I always have my rose-colored glasses on!)
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On a scale of 1-10, how open are you to discussing areas of your life that you would like to change? (1=Not at all; 10=I am an open book!)
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Are you at all worried about using the clay? (no artistic skills are necessary...I PROMISE!)
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Yes, I don't have an artistic bone in my body
A little, but I should be fine. It's not about art, right? (RIGHT!)
A little...I tend to have sensory issues.
Not at all worried...I love working with my hands!
I have never used clay, but am willing to give it a try!
Other (please specify below)
Other
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How did you hear about the New Moon Self-Development?
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Facebook/Social Media
Internet Search
Advertisement
Newspaper/Calendar
Email
Referral from a past client/colleague/friend (please specify in Other)
I know Karen and wanted to give it a try
Went to a workshop and saw how powerful the clay work is
Other (please specify below)
Other:
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What is your primary goal in working with Karen LoGiudice/New Moon Self-Development Center?
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