Supplemental History Form

Please use the following outline as a guide in providing me with history about yourself which may be helpful to me in my work with you. I would also like you to complete the history form that is available on my web site (www.drpaulschenk.com). While you need not address every topic covered here, each is included because all have proven to be important at one time or another with other clients. If you will be faxing your responses to me, please use black ink as it reproduces much more reliably than other colors.

If time permits, please mail your responses using the envelope enclosed. You may also fax them to me at my office (770-671-8493). If time does not allow, please bring your responses with you when you come for your appointment. Thank you in advance for the time you spend giving these questions your consideration. Your efforts will help me be more effective in my work with you. Please take the time to read the section on my web site that describes my approach to past life therapy. There are two articles relevant to this on the web site as well. Time permitting, you may also wish to obtain a copy of my book published in late 2006 that explores some applications of hypnosis in this fashion.

Please use your word processor to complete the following form. Done in table format, each section will expand to allow you to be as detailed as needed.

Demographic Information
Name, address, phone number, date of birth
Marital Status
First names of prior spouses or partners
Names and ages of all children including deaths, miscarriages, abortions

Work History
Current job title, length of employment, attitude about your work
Brief history of previous employment

Physical Health History
Significant past illnesses
Significant injuries, both chronic and resolved
Prior surgery
Current health problems
List all current medications. If you recently stopped taking any medications, please list those.

Prior Therapy History
Briefly describe prior or current therapy, when this took place, and the primary issues addressed.
If currently in therapy, does your therapist know you're exploring past life issues? If not, please address this with your therapist prior to our meeting.

Legal History
Prior legal involvement whether as plaintiff or defendant. Outcome?
Any current legal involvement. Please explain.
Possible future legal involvement of which you are aware.
Please note that the use of hypnosis can have serious adverse consequences for any matter which may be heard before the court. "Hypnotically refreshed memories" are not admissable in many states and may make it impossible to pursue legal action.

Prior history of trauma
Emotional abuse or neglect
Physical abuse
Sexual harassment or abuse
Other traumatic events such as natural disasters, car accidents, witnessing events which were traumatic such as a violent crime or accident.
If yes to any of the above, did you get therapy or counseling? Was it helpful?

Family of Origin
Briefly describe your parents, their ages, whether they are still alive and if not when they died; list siblings whether alive or dead, their ages, and anything you see as significant in the life of the family, whether because it was very positive or very challenging.
Childhood and adolescence:

Briefly describe your school history and education with the year of your high school graduation, college attendance and degrees, and other specialty training.

Summarize your dating during adolescence and beyond.

Describe hobbies, clubs, and other leisure activities.
Describe how you see yourself fitting in with your family of origin.

Religion and spirituality
Briefly summarize your religious upbringing and your attitudes about it; what role does religion currently play in your life as distinct from your current spiritual beliefs and practices.

Reincarnation and Past Life Therapy
When and how did you become interested in the topic of reincarnation and past lives?
What kind of books, if any, have you read on the subject?
Have you previously had any past life therapy or regression therapy? If so, when, with whom, and what were the results?
Have you had any spontaneous experiences which seem like they might have been memories from other lifetimes?
Are you drawn to particular time periods in history or particular geographical locations?
Any aversion to particular time periods in history or particular geographical locations?

Prior Experiences with Hypnosis
Has anyone ever tried to use hypnosis with you in the past? If so please describe the results.
Have you ever witnessed hypnosis being used, whether professionally or as entertainment? If so, please describe (especially your reactions to what you saw).
Please describe any concerns or apprehensions you may have about hypnosis.

Other paranormal experiences (your own or those of someone close to you)
Near-death experiences
Pre-cognitive dreams
Deja-vu experiences
Contacts with angels, spirit guides, etc.
Have you had any negative paranormal experiences? Please describe.

Motivations for exploring past life therapy at this time
Please describe any specific issues, themes, or relationships that you would like to explore.
If there are any issues or topics you wish to avoid, please describe them.
If relevant, does your partner or spouse know that you wish to explore past lives? Does this have the support of the significant people in your life?

Office address:	For all U.S. mail please use the address below:

Paul W. Schenk, Psy.D.	Paul W. Schenk, Psy.D.

2295 Parklake Dr., NE, Suite 430	4487 Village Springs Pl

Atlanta, GA 30345-2812	Dunwoody, GA 30338-2401

Phone: 770-939-4473

Fax: 770-671-8493

Email: drpaulschenk@att.net

Web: www.drpaulschenk.com

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