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Your Consultation Questionnaire with Nina Lau Branson

Filling Out Your Consultation Questionnaire

In preparation for your Dynamic Emotional Integration^® consultation, please fill out and submit this questionnaire.

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

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

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This field is for validation purposes and should be left unchanged.

Your Consultation Questionnaire

Instructions
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!

Your Name(Required)

Your Email(Required)

Your Time Zone(Required)

Your Phone Number(Required)

About Your Situation

Your Current Concerns(Required)

I have current concerns about (mark any that apply):

Excessive or insufficient emotion

Hypersensitivity

Hyper-empathy

Insensitivity or low empathy

My eating and self-care practices

My health and health-care

Sleep

Work

Distractions and addictions

Finances

Relationships

Other

Further Details

If you checked anything in the boxes above, please explain here:

About You

1. I am comfortable speaking up for myself, even during conflicts(Required)

Always

Depends on the situation — but usually

Depends on the situation — but sometimes

Rarely

Never

2. I feel heard and respected in my interpersonal relationships(Required)

Always

Depends on the situation — but usually

Depends on the situation — but sometimes

Rarely

Never

3. I take good care of myself, and I can say no to demands on my personal time(Required)

Always

Depends on the situation — but usually

Depends on the situation — but sometimes

Rarely

Never

4. I can make clear distinctions between my own emotions and the emotions of others(Required)

Always

Depends on the situation — but usually

Depends on the situation — but sometimes

Rarely

Never

5. I am able to choose whether I feel other people's emotions or not(Required)

Always

Depends on the situation — but usually

Depends on the situation — but sometimes

Rarely

Never

6. I tend to remain calm and focused in emergencies(Required)

Always

Depends on the situation — but usually

Depends on the situation — but sometimes

Rarely

Never

7. When I think of large projects, or places I have to get to at a specific time, I feel pretty relaxed(Required)

Always

Depends on the situation — but usually

Depends on the situation — but sometimes

Rarely

Never

8. I make time to laugh and have fun, and I look forward to the future(Required)

Always

Depends on the situation — but usually

Depends on the situation — but sometimes

Rarely

Never

9. I tend to trust that new situations and new relationships are going to work out(Required)

Always

Depends on the situation — but usually

Depends on the situation — but sometimes

Rarely

Never

10. I'm able to change my mind when I discover better information and new ideas(Required)

Always

Depends on the situation — but usually

Depends on the situation — but sometimes

Rarely

Never

11. I can relax and calm myself down, and I have reliable self-soothing skills(Required)

Always

Depends on the situation — but usually

Depends on the situation — but sometimes

Rarely

Never

12. I'm comfortable talking about my talents and my achievements(Required)

Always

Depends on the situation — but usually

Depends on the situation — but sometimes

Rarely

Never

13. I can move on from situations that aren't healthy or really can't work(Required)

Always

Depends on the situation — but usually

Depends on the situation — but sometimes

Rarely

Never

14. I have a fairly easy time changing problem behaviors when I become aware of them(Required)

Always

Depends on the situation — but usually

Depends on the situation — but sometimes

Rarely

Never

About Your Support System

Relationships(Required)

I have supportive and nurturing relationships with (check all that apply):

Myself

My partner or spouse

My parent(s)

My sibling(s)

My child(ren), niece(s), nephew(s)

My extended family

My friends

My health and healing professional(s)

My neighbors

My work colleagues

Animals

Other

Arts and Expressive Activities(Required)

I express myself artistically through (check all that apply):

Ceramics/Sculpture

Cooking/Baking

Dance/Movement/Sports

Fabric/Needlework/Textile Arts

Interior Design/Renovation

Mathematics/Computer Programming/Web Design

Metalwork/Jewelry Making

Music/Singing/Composing

Painting/Drawing/Drafting/Graphic Design

Personal Adornment

Photography

Theater Arts

Woodworking/Carving/Furniture Making

Writing/Journaling/Poetry

Other

Self-Care and Personal Growth Activities(Required)

Check all that apply:

Artistic Expression

Being in Nature

Being with Animals

Community-building

Empathic Activism

Healthy Eating

Laughing, Playing, and Having Fun

Loving Relationships

Mentoring/Teaching

Mindfulness Practices

Movement/Exercise

Reading and Research

Regular, Healthy Sleep

Social Justice Work

Travel

Other

Work-Related Support(Required)

I have support in my working life from (check all that apply):

My Supervisor(s)

My Manager(s) or Boss(es)

The Corporate Culture

My Colleagues

My Employee(s)

My Supplier(s) or Sub-Contractor(s)

My physical surroundings and workspace

I am self-employed; I fulfill most of these roles and/or create my workspace myself

I am a student, retiree, and/or not working at this time

Other

Further Details

If you marked “other” in the boxes above, please explain here:

About Your Support System

What specific issues or concerns do you want to focus upon?(Required)

Consultation Agreement(Required)

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).

Δ

Thank you! You will receive a copy of your answers by e-mail.

I look forward to speaking with you soon!

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