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Mental Health Seminar & Retreat Registration Form

Please complete every question on the consultation form and submit with a payment of $1500.00.
If you have any questions in the interim, please call 731-244-2140. We are here to serve.
Providing the following information will allow a better understanding of your condition, and enable us to help you more. Explain fully where necessary.

Mental Health Evaluation Form (37 KB)

First Name

Last Name

Street Address

Apartment, suite, unit etc.

Country

City

State / Province / Region (if applicable)

Postal Code / Zip Code

Home Phone

Cell Phone

E-mail Address

Birth Date

Birthplace

Nationality

Sex

Height

Weight

Occupation

Religion Preference

MEDICAL HISTORY

Give medical history - names and dates of past ailments, operations (anything you feel significant, including past complaints).

When did you last consult a physician?

For what reason?

What are you currently being treated for?

What specific conditions would you like this consultation to address?

List all medicine, pills, or drugs you are taking now

List mineral and/or vitamin supplements you are taking/how many and how often

Do you have indigestion?

Yes No

Gas?

Yes No

Bloating?

Yes No

How Often?

What foods tend to cause indigestion, bloating or gas?

How often do you have bowel evacuations?

Color & Texture

Do you have Diarrhea?

Yes No

Constipation?

Yes No

What color is your urine usually?

Do you wear eyeglasses?

Yes No

Contact lenses?

Yes No

How many years?

What health ailments, illnesses or challenges have you suffered with in the past and/or are currently suffering with?

Enter other health ailments, illnesses or challenges here...

List all medicine, pills, or drugs you are taking now

GODLY TRUST

Occupations

What hours do you work?

Health of spouse (if applicable):

How many children do you have?

Ages

Health of children

Recreational activities enjoyed

Hours per week viewing TV

Do you often feel guilty about past mistakes?

Yes No

Do you worry about the future?

Yes No

Do you have stress?

Yes No

Do you suffer with depression?

Yes No

Check the following categories which cause stress

On a scale of 1 to 10 rate your stress level (1= very little stress and 10=an extreme amt. of stress)?

Do you enjoy the work that you do?

Yes No

If Not, Explain

Are you developing your mental and spiritual capabilities by daily study, meditation and prayer?

Yes No

Are you involved in some type of activity in which you are helping others

Yes No

The following space is provided for those who would like to elaborate more on the causes of their stress, depression and other negative emotions.

OPEN AIR

How many hours daily do you spend out of doors?

Do you sleep with your windows closed?

Yes No

Are you able to breathe fresh air while you are working?

Yes No

Is the building where you work a none-smoking facility?

Yes No

DAILY EXERCISE

How often do you exercise?

Describe the exercise:

How do you feel after you exercise?

SUNSHINE

How much time daily do you spend out of doors in the sunlight?

Do you often get sunburned?

Yes No

Do you visit tanning beds?

Yes No

Are you afraid of getting skin cancer?

Yes No

PROPER REST

What time do you go to bed?

What time do you awaken?

What time is your last meal before retiring?

Do you snack just before bedtime?

Yes No

Do you wake up during the night and snack?

Yes No

If so, what do you eat?

Do you have trouble sleeping?

Yes No

Explain

LOTS OF WATER

How much water do you drink daily?

What type? (spring, filtered, distilled, tap)

Check below the beverages you drink and indicate how much of each

BEVERAGE

Soda

NAME BRAND

#OF Glasses, Cans or Bottles Daily

Coffee

Tea

Fruit Juice

Punch

Milk

Other

What is the usual color of your urine?

Explain your understanding of the principles of hygiene

ALWAYS TEMPERATE

Do you ingest caffeine in any form?

Yes No

If so, for how many years?

Have you ingested caffeine in the past?

Yes No

For how many years?

If so, when did you stop?

Do you smoke or chew tobacco?

Yes No

Indicate which

If so, for how many years?

Have you used tobacco in the past?

Yes No

For how many years?

If so, when did you stop?

Do you drink alcohol?

Yes No

If so, what kind?

For how many years?

Have you drank alcohol in the past?

Yes No

For how many years?

NUTRITION

Do you overeat?

Yes No

Do you feel stuffed after your meals?

Yes No

Do you eat between meals?

Yes No

Do you drink with your meals?

Yes No

If so, what liquids?

Do you wear removable dentures or plates?

Yes No

Do you eat fast?

Yes No

How long does it take you to eat?

Do you have a peaceful environment at meal times?

Do you have set meal times?

Yes No

Are you following any special diet?

Yes No

Explain what type

Do you eat animal products?

Yes No

If so, what kind?

How Often?

Do you eat dairy products?

Yes No

What kind of dairy products

Milk Cheese Egg

Do you eat desserts, candy or other sweets regularly?

Yes No

Explain how often and what Type

What time do you eat breakfast?

What foods do you usually eat?

How often do you eat a tossed green leafy salad?

How often do you eat steamed or cooked vegetables?

How often do you eat fruits?

How often do you eat soup or stew?

What time do you eat lunch (dinner)?

What foods do you eat?

What time do you eat supper?

What foods do you eat?

I Agree and understand That This Questionnaire And The Educational Information Given In This Consultation Is Biblical Life-style Education And Is Not Intended To Diagnose Or Treat Any Disease, Ailment Or Abnormality.

BILLING INFORMATION

Full Name

E-Mail Address

Address

Suburb / City

Postcode

State

Contact Phone

PAYMENT OPTIONS

Submit $1500 donation to complete the consultation process.

$1500 DONATION TO HELP US COVER THE EXPENSES INVOLVED.

Credit Card Number

Credit Card Holder

Credit Card ExpiryExpiry date - Month / Year

/

CVV CodeThe code on the back of your card

We Accept Visa We Accept MasterCard

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