ANDREW SHUGYO DAIJO BONNICI, PH.D.
Applied Meditation Therapy & Somatic Core-Self Intelligence

P.O. Box 44573, Kamuela, HI 96743
Phone: (808) 880-1395

Video & Telephone Sessions
The Heart of Gratitude is a Treasure Beyond Compare.

ZenDoctor.Com

YOUR COUNSELING INTAKE FORM & FEE INFORMATION


SESSION FEE

My standard fee for individual training,
counseling, mentoring, teaching, and
consultation is $150.00 per
hourly session.

COUNSELING INTAKE INFORMATION FORM

Please Tell Me About Yourself.

First Name: Last Name:

Occupation: Birth-Date: Age:

City/Town: State/Province

Country: Zip/Post Code:

Phone: Fax #:

Single, Married, or Committed Relationship?

Ages of Children? Are they living with you?

Please list any Hobbies, Sports, or Other Activities that You Enjoy.

Education Completed: Religion Raised in:

Spouse's or Companion's religious upbringing?

Do you Currently Practice a Religion or Spirituality?

If yes, how would you Describe it?

Companion's or Spouse's spiritual practice:

Do you have any Meditation Experience?

How Long:

Kind of Meditation You Practice?

Group Practice?

What Kind of Group:

Are you taking any prescribed medications?

Please list medications & reasons for taking them:


Drug or Alcohol Use? Please Specify.

Have you been in Counseling Before?

If Yes, Please Specify Why:


What Areas Below Touch upon Your Immediate Concerns:

Psychological: Purpose: Interpersonal: Meaning:

Emotional: Creativity: Spiritual: Faith: Health:

Meditation: Sexuality: Breathing: Finances:

Integrity: Life Stress: Compassion: Values:

Wonder: Attitudes: Mindfulness: Anger:

Self-Esteem: Not-Knowing: Inner Peace:

Fear: Confidence: Anxiety: Joyfulness:

Share with me three categories that are
the most important to you Now and why:




CREDIT CARD INFORMATION

Please Note: This Form will not Allow you to Submit Unless
you Fill in your E-mail Address, Visa Card Number, Name on
Card, and its Expiration Date.

TODAY'S DATE: E-MAIL:
PLEASE SELECT THE METHOD OF PAYMENT.
VISA: MASTER CARD: AMERICAN EXPRESS:
NAME AS IT APPEARS ON CARD:
CREDIT CARD NUMBER:

EXPIRATION DATE:
VALIDATION CODE (Three Digits in Back of Credit Card):


Describe for me your Specific Counseling Need(s). What is your purpose for scheduling a counseling session? Also, please provide me with Days and Times that you would be available for your video or phone counseling session. I schedule video or phone counseling sessions only on Mondays, Tuesdays, Wednesdays, and Thursdays. Use the World Time Zone that you are in and I will recalculate it according to my Time Zone.


After you submit this form, I will e-mail you to set up a mutually agreed upon time for your appointment. If you do not hear from me within a 48 Hours, send me an e-mail and I will respond to you immediately.

THREE THINGS TO REMEMBER

1) All counseling, education, and training provided by Dr. Bonnici is designed to support,and not replace, medical care or any relationships that currently exist between clients and their physicians, psychiatrists, or therapists.

2) All video, telephone and email communications are kept strictly confidential. Only two exceptions exist to confidentiality: a)When I have knowledge that a client is a serious danger to self or others, and b) When there is any indication that a child, elder, or disabled person is at risk because of abuse or neglect. In either case, I would need to notify the social agencies in your area.

3) Cancellations must be made more than 24 hours in advance. Failure to give 24 hour notice will result in your being charged for the scheduled counseling session.


Please Check Information Submitting.

Press Reset Button to Clear Form.