Your DEI Consultation Questionnaire with Jessica Moore

Filling Out Your Consultation Questionnaire

In preparation for your Dynamic Emotional Integration® consultation (also known as DEI), please fill out and submit this questionnaire.

Your information — here and in your DEI consultation — will remain confidential.

The information you provide here will help me understand your emotional strengths and challenges, the current social and emotional situations you’re dealing with, and the supportive resources you have in your life. I look forward to learning more about you! ~ Jessica Moore

Your DEI Consultation Questionnaire

As you answer these questions, treat them as a snapshot of your current situation, behavior, skills, challenges, and resources – so that we can focus clearly on your present-day situation. Thank you!

About Your Situation
I have current concerns about (mark any that apply and explain below):
If you checked anything in the boxes above, please explain here:
About You
About Your Support System
I have supportive and nurturing relationships with (check all that apply):
I express myself artistically through (check all that apply):
Check all that apply:
I have support in my working life from (check all that apply):
If you marked \"other\" in the boxes above, please explain here:
About This Consultation
I understand that a Dynamic Emotional Integration® consultation is not a substitute for psychotherapy or medical advice, and I take full responsibility for alerting my healthcare and mental health practitioners about any changes resulting from this consultation that may affect my current treatment (if any).

Thank you! You will receive a copy of your answers by email.

I look forward to speaking with you soon!