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Returning Student |
| Name * | |
| Street Address or P. O. Box | |
| (Apartment Number) | |
| City/State-Province/Zip | |
| Country | |
| E-mail Address * | |
| Web Site URL (if any) | |
| Telephone # (include area code) * | |
| Place of Employment | |
| Occupation | |
| Birthday |
| How much time do you give (on the
average) to your inner life or self-care (e.g., prayer, meditation, body work, journaling, silence, study, dream work,...)? |
| What is your previous experience with
counseling, therapy, coaching, or spiritual guidance? |
| Describe any significant physical or psychological issues. Include medications that may influence your physical or mental functioning.
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| What is your primary reason for seeking
individual work at this time? |
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Select areas below that you are particularly interested or areas you would definitely not want to explore. You do not have to mark every item, just those that definitly apply. You will have further opportunity to express preferences as you work with Mary. Where are you now?
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In submitting this request, I acknowledge that I am in good health or taking responsibility for my physical and mental health. I understand that Mary Rees is a Spiritual Director, a Meditation Teacher, and an Educational Diagnotician - not a doctor or a therapist. She will support me in meeting my personal goals. However, I am responsible for my life decisons and will seek other appropriate professional help as needed for mental and physical health. | |||||||||||||||||||||||||||||||||||||
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PO Box 20161
Houston, Texas 77025
713-662-2743
mary@citta101.org© 1998 - 2006 Mary Rees