DEI Questionaire – Vermont Equine Assisted Coaching

Your Consultation Questionnaire

In preparation for your Dynamic Emotional Integration® consultation, please fill out and return this questionnaire to me.

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.

The information you provide below will help me understand your current emotional strengths and challenges, the current socio-emotional situations you’re dealing with, and the supportive resources you have in your life.

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

Your Name *

First

Last

Email *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

If you checked anything in these boxes, please explain here.

ABOUT YOU - 1. I am comfortable speaking up for myself, even during conflicts:

2. I feel heard and respected in my interpersonal relationships:

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

4. I can make clear distinctions between my own emotions and the emotions of others:

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

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

8. I make time to laugh and have fun, and I look forward to the future:

9. I tend to trust that new situations ane new relationships are going to work out:

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

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

12. I am comfortable talking about my talents and achievements:

13. I can move on from situatuions that aren't healthy or really can't work:

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

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

My supervisor(s) or boss(es)
The corporate culture
My colleague(s)
My employee(s)
My supplier(s) and/or subcontractor(s)
My physical surroundings and workspace
I am self-employed; I fulfill most of these roles and/or create my workspace
I am a student, retiree, and/or not working at this time
Other

ABOUT THIS CONSULTATION - What specific issues or concerns do you want to focus upon?

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). *

SIGNATURE

Date *