Phone Consultations
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Questions • Payment • Verify • Receipt

If you would like a psychological or psycho-spiritual counseling or consultation session by phone, please complete the following questionnaire and submit via e-mail. Your questionnaire will be reviewed by Dr. Laura Sturgis prior to your phone consultation.

1. Name

1. Name
2. Date of Birth

2. Date of Birth
3. Marital Status

3. Marital Status

4. Children

4. Children

Name

Name
Age

Age
Name

Name
Age

Age
Name

Name
Age

Age
5. Are you currently under a doctor's care for any medical problems?

5. Are you currently under a doctor's care for any medical problems?

Please describe

Please describe


6. Surgeries

6. Surgeries
7. Medications

7. Medications


8. Hospitalizations

8. Hospitalizations

Medical

Medical

Date

Date
Problem

Problem
Psychiatric

Psychiatric

Date

Date
Problem

Problem
Alcohol/Drug Treatment

Alcohol/Drug Treatment

Date

Date
Problem

Problem
9. Any Strong negative or traumatic events in childhood or adulthood?

9. Any Strong negative or traumatic events in childhood or adulthood?

Please describe

Please describe


10. Family Social History

10. Family Social History

(Please click all that apply)
Physical Neglect

Physical Neglect

Emotional Neglect

Emotional Neglect

Physical Abuse

Physical Abuse

Emotional Abuse

Emotional Abuse

Sexual Abuse

Sexual Abuse

Abandonment/Rejection

Abandonment/Rejection

Betrayal

Betrayal

Unresolved Death Issues

Unresolved Death Issues

Other

Other
11. Education

11. Education

(Click on highest level of educational degree completed)
12. Difficulties

12. Difficulties

Please click the areas you feel you have had or are currently difficulty with
13. Do you have any prior experience with

13. Do you have any prior experience with

Type
14. E-mail Orders

14. E-mail Orders

First Name

First Name
Last Name

Last Name
E-mail

E-mail
Company

Company
Street Address

Street Address
City

City
State/Province

State/Province
Postal Code

Postal Code
Country

Country
Telephone

Telephone
15. Best Time to Call (First Choice)

15. Best Time to Call (First Choice)
16. Best Time to Call (Second Choice)

16. Best Time to Call (Second Choice)
17. Length of Session

17. Length of Session

18. How did you hear about us?

18. How did you hear about us?
II. Postal Mail Orders

II. Postal Mail Orders

Please complete and print the entire phone consultation personal and approval information sections, and send it along with a certified money order or cashier's check for the amount corresponding to the length of session you requested to:

Transformational Living Center
2851 East Manoa Road, Suite 1-203
Honolulu, HI 96822-1858


You will be notified via e-mail of the day and time to call for your phone appointment.
Copyright © Transformational Living Center (Honolulu, HI)
dr.laurasturgis@gmail.com