Email Client Name * Client Email * Client Phone Number Coach Name * Appointment Date * Please answer the following questions using a scale of 0-5 Do you have any anxiety about having symptoms of PTSD right now? * 0 - No symptoms, 3 - Some discomfort with anxiety, 5 - Very Anxious How well did you sleep last night? * 0 - Unable to sleep majority of night, 3 - Disturbed enough to bother you today, 5 - Had great sleep How much do you appreciate learning to do the Neurokinesis hand technique? * 0 - You don't think it helps, 3 - Helps you more than expected, 5 - It has changed your life for the better and more than you thought possible How much does your family or friends think you have improved since you started using the Neurokinesis hand technique? * 0 - They don't think it has helped, 3 - They tell you they know it has helped, 5 - They voluntarily tell others how much it has changed your and their life for the better How well have you done remembering to use the hand technique the second you need to? * 0 - You didn't use at all, 3 - Used only when anxious or fearful, 5 - Practice it daily and use it the second you feel unsafe, ashamed uncomfortable or anxious about the return of PTSD symptoms or events Comments
