QUALIFICATION TEST FORM QUALIFICATION TEST FORM Qualification Form GENERAL INFOFirst Name:Last Name:Date:Address:Phone/MobileEmail:Age: Sex: Male FemaleMarital Status: Married Single DivorcedHow do you find us?PreviousNextTELL US ABOUT YOURSELFWhich area(s) of your life are you wanting to improve?How long have you been wanting to get help with this? Are you really ready to start improving your life?Have you decided on something specific that you would like to achieve with a Freedom Coach or Counselor?Is there anything else that you would like to communicate regarding your goals?Which of our services are you interested in?PreviousNextSOUL HEALTH Please describe your current spiritual wellness practices, such as meditation, yoga, faith healing, self-help books, gardening, etc. PreviousNextBODY HEALTHWeHelp Group believes that a person should be under the care of a medical doctor if there is a medical condition needing attention. Are you seeking the advice of a medical doctor? If yes, please provide details. Do you agree with the diagnosis? We have strict policies on accepting someone who has severe medical conditions, such as cancer. Have you sought the advice of a holistic practitioner to confirm the healing approach?We have strict policies on the use of drugs (street drugs and prescription drugs) due to the powerful mind-altering effects they cause. Are you currently taking any drugs? If yes, please provide details.Do you sleep well? How many hours of sleep do you need to feel alert and well rested?What is your current diet like? (what do you usually eat on a regular basis)Do you take vitamins? If so, what kind?Do you drink alcohol? If so, how often?PreviousNextMIND HEALTHWeHelp Group supports the prevention of human rights abuses in the name of mental health.Are you currently seeking or have you sought the advice of a psychiatrist or psychologist? If yes, please provide details of type of practitioner, reason for seeking their advice, details of any mental hospital stay, psychotropic drug use, electroshock therapy (ECT) received or any sort of psychosurgery where devices have been implanted in the brain.Have you ever considered or attempted suicide? If yes, please give details as to when, what actions were taken, any psychiatric treatment received, etc.Please describe, if any, other mental health or psychology practices you have used, such as hypnosis, light therapy, CBT (cognitive behavioral therapy), etc.PreviousNextMISCELLANEOUSIs there anything else you’d like to tell us?PreviousNextACKNOWLEDGEMENT I attest that the information I have provided above is true and factual. I authorize WeHelp Group Inc., to retain the information of this form in order to potentially provide Freedom Coaching and Freedom Counseling to me. I understand that this information will be kept confidential. Full Name:Date:SERVICE RECOMMENDED (FOR OFFICE USE ONLY): Previous Submit Form
