Goal Balance/ Emotional Clearing

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Name *

Gender *

Female

Male

Pregnant or Nursing *

Yes

Date of birth *

YYYY

Email *

Cell # *

I am a member of Jon and Deanna's doTERRA team *

Yes

If yes: Member ID#

Referred by: *

Do I have permission to test you and work on you? *

Yes

I understand Jon & Deanna Nichols are not medical professionals and that the information provided is not intended to diagnose or treat any disease or illness. *

Yes

Your Goal:

Give specifics of your goal and feel free to include as much info as you like about how you feel, things happening in your body you would like to see change and dates to reach the goal. Anything you would like me to include in this goal balance. What would you like to gain from this session?

EMOTIONAL CLEARING:

The effectiveness of your session is related to your best efforts to list 5-10 things in each category that were significant stressors or at one time created negative emotions, thoughts, perceptions for you, even if you believe it is no longer a problem for you. Please keep answers brief and without specifics but clear enough that YOU know what you are referencing.

Please write down 1-3 words to jog YOUR memory about each of the people, places, incidents that were unpleasant, upsetting, stressful, traumatic, frightening, sad, or in any way negative in your past or present. It would be very helpful for me if you will try to group them chronologically or by category. Examples -Chronologically: my birth, early childhood, adolescence, early adult, middle age, etc or by category: college, health, marriage, realtor career, retirement. *

How I feel about myself *

How I feel about other people *

How I feel about money/wealth *

How I feel about the world *

How I feel about love *

How I feel about God/religion/supernatural forces *

Write down the names of people in your life who have had a powerful influence - positive or negative- on your life and who you have become. *

Write down the names of family and friends whose relationships are most important to you *

Write down the names of business associates whose relationships are instrumental in the growth of your business. *

Write down the names of people with whom you WANT to develop a relationship personally or professionally. *

Write down a key word/phrase for any negative history, events, situations you have no memory of but were told or have learned about your family, your own birth, your heritage *

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