Pre-Session Prep Form

The purpose of this form is for you to get into the habit of being responsible for yourself, so that over time, you have a pattern of regularly (weekly or fortnightly) keeping an eye on the nurturing you do of your inner child, who takes care of your body, your emotions, your physical well-being.

Ask yourself, if I had a real child would I take care of that child better than I do myself?  If the answer is yes, then you really will delight in completing this form and learning to have respect for yourself, which will increase your integrity.

Please select the checkbox option or fill in the text area, as it applied to you and your daily habits and select what is most accurate for you.

*(denotes required field)

First Name:*

Last Name:*

E-Mail Address:*

1. I ate 3 healthy meals a day in the past week or fortnight:*

Yes
No
Often
Sometimes
Nope

2. I exercised:*

Daily
Every couple of days
Once a week
Once a fortnight

3. I practised deep breathing throughout the day while breathing in peace calm and love:*

Yes
No
Quite often
Often
Not very often
I forgot about it

4. My caffeine intake is down to 1 or 2 cups per day:*

Yes
No

5. I'm following a regular nightly sleep routine:*

Yes
No
Sometimes

6. I praised myself and talked to my subconscious also known as my inner child:*

Lots of times a day
Sometimes each day
Not very often
I forgot about my subconscious

7. I am noticing my thoughts are:*

Very optimistic
Optimistic
Occasionally optimistic
Not optimistic

8. I found it easier to relax:*

All the time
More often than not
Occasionally
Not often

9. I feel more in control:*

Yes
No
Sometimes

10. I drink 2 to 3 litres of water each day:*

Yes
No
Some days

11. I have 3 to 4 alcohol free days a week:*

Yes
More than that
Less than that

12. Today I rate my mood out of 10 where 10 is the best it can be at:*

10
9
8
7
6
5
4
3
2
1

13: Remember that feelings aren't facts and are subject to change. On AVERAGE since you were last seen please describe your mood*

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STANDARD DRINKS OF ALCOHOL

• A standard drink of alcohol is defined as a drink that contains 10 grams of pure alcohol.
• Different alcoholic drinks contain different amounts of pure alcohol.

For example, each of the drinks below are equal to approximately one standard drink.

So, 1 std drink =

• 2 x 285 ml pots/middies/schooners/handles of light beer (2.7 per cent Alc./Vol).
• 1 x 375 ml stubby of mid strength beer (3.5 per cent Alc./Vol).
• 3/4 of a 375 ml stubby of full strength beer (4.9 per cent Alc./Vol).
• 1 x 285 ml pot/middy/schooner/handle of full strength beer (4.9 per cent Alc./Vol).
• 100 ml of wine (12 per cent Alc./Vol).  Remember, those big wine glasses hold approximately 300 ml, which is 3 standard drinks in one big glass.
• 2/3 x 330 ml bottle of alcoholic soda (5.5 per cent Alc./Vol).
• 30 ml of spirit or liqueur (40 per cent Alc./Vol).
• Recommended intake of alcohol if you have alcohol, is no more than 2 standard drinks per session, and have at least 3 alcohol-free days per week. Children should not be given alcohol and the older that a child is, the better, so leave it until age 18!

From:  http://www.mydr.com.au/addictions/standard-drinks