Pre & Post Program Symptom Questionnaire Survey

This symptom inventory will take about 15-20 minutes and is best completed on a larger device. It will be completed BEFORE you start the program *and* AFTER you complete your program.

Please allow adequate time, but know that you can start where you left off if you complete on the same device.

	Not at all (in the last 2 years)	Daily	Weekly	Monthly	Quarterly	Yearly
Prescribed psychiatric medications	Prescribed psychiatric medications Not at all (in the last 2 years)	Prescribed psychiatric medications Daily	Prescribed psychiatric medications Weekly	Prescribed psychiatric medications Monthly	Prescribed psychiatric medications Quarterly	Prescribed psychiatric medications Yearly
Other Doctor-prescribed medications that alter your mood	Other Doctor-prescribed medications that alter your mood Not at all (in the last 2 years)	Other Doctor-prescribed medications that alter your mood Daily	Other Doctor-prescribed medications that alter your mood Weekly	Other Doctor-prescribed medications that alter your mood Monthly	Other Doctor-prescribed medications that alter your mood Quarterly	Other Doctor-prescribed medications that alter your mood Yearly
Alcohol	Alcohol Not at all (in the last 2 years)	Alcohol Daily	Alcohol Weekly	Alcohol Monthly	Alcohol Quarterly	Alcohol Yearly
Marijuana	Marijuana Not at all (in the last 2 years)	Marijuana Daily	Marijuana Weekly	Marijuana Monthly	Marijuana Quarterly	Marijuana Yearly
Psychedelics (plant medicine, MDMA, Ketamine, Ecstasy, etc.)	Psychedelics (plant medicine, MDMA, Ketamine, Ecstasy, etc.) Not at all (in the last 2 years)	Psychedelics (plant medicine, MDMA, Ketamine, Ecstasy, etc.) Daily	Psychedelics (plant medicine, MDMA, Ketamine, Ecstasy, etc.) Weekly	Psychedelics (plant medicine, MDMA, Ketamine, Ecstasy, etc.) Monthly	Psychedelics (plant medicine, MDMA, Ketamine, Ecstasy, etc.) Quarterly	Psychedelics (plant medicine, MDMA, Ketamine, Ecstasy, etc.) Yearly
Other Recreational drugs	Other Recreational drugs Not at all (in the last 2 years)	Other Recreational drugs Daily	Other Recreational drugs Weekly	Other Recreational drugs Monthly	Other Recreational drugs Quarterly	Other Recreational drugs Yearly

Not at all (in the last 2 years)

Daily

Weekly

Monthly

Quarterly

Yearly

Prescribed psychiatric medications

Prescribed psychiatric medications Not at all (in the last 2 years)

Prescribed psychiatric medications Daily

Prescribed psychiatric medications Weekly

Prescribed psychiatric medications Monthly

Prescribed psychiatric medications Quarterly

Prescribed psychiatric medications Yearly

Other Doctor-prescribed medications that alter your mood

Other Doctor-prescribed medications that alter your mood Not at all (in the last 2 years)

Other Doctor-prescribed medications that alter your mood Daily

Other Doctor-prescribed medications that alter your mood Weekly

Other Doctor-prescribed medications that alter your mood Monthly

Other Doctor-prescribed medications that alter your mood Quarterly

Other Doctor-prescribed medications that alter your mood Yearly

Alcohol

Alcohol Not at all (in the last 2 years)

Alcohol Daily

Alcohol Weekly

Alcohol Monthly

Alcohol Quarterly

Alcohol Yearly

Marijuana

Marijuana Not at all (in the last 2 years)

Marijuana Daily

Marijuana Weekly

Marijuana Monthly

Marijuana Quarterly

Marijuana Yearly

Psychedelics (plant medicine, MDMA, Ketamine, Ecstasy, etc.)

Psychedelics (plant medicine, MDMA, Ketamine, Ecstasy, etc.) Not at all (in the last 2 years)

Psychedelics (plant medicine, MDMA, Ketamine, Ecstasy, etc.) Daily

Psychedelics (plant medicine, MDMA, Ketamine, Ecstasy, etc.) Weekly

Psychedelics (plant medicine, MDMA, Ketamine, Ecstasy, etc.) Monthly

Psychedelics (plant medicine, MDMA, Ketamine, Ecstasy, etc.) Quarterly

Psychedelics (plant medicine, MDMA, Ketamine, Ecstasy, etc.) Yearly

Other Recreational drugs

Other Recreational drugs Not at all (in the last 2 years)

Other Recreational drugs Daily

Other Recreational drugs Weekly

Other Recreational drugs Monthly

Other Recreational drugs Quarterly

Other Recreational drugs Yearly

	Not Applicable - Did not use this modality	No impact (I used the modality and had no impact or symptoms worsened)	Slight	Moderate	Significant	Very significant
Talk therapy (CBT or DBT)	Talk therapy (CBT or DBT) Not Applicable - Did not use this modality	Talk therapy (CBT or DBT) No impact (I used the modality and had no impact or symptoms worsened)	Talk therapy (CBT or DBT) Slight	Talk therapy (CBT or DBT) Moderate	Talk therapy (CBT or DBT) Significant	Talk therapy (CBT or DBT) Very significant
EMDR	EMDR Not Applicable - Did not use this modality	EMDR No impact (I used the modality and had no impact or symptoms worsened)	EMDR Slight	EMDR Moderate	EMDR Significant	EMDR Very significant
Internal Family Systems therapy	Internal Family Systems therapy Not Applicable - Did not use this modality	Internal Family Systems therapy No impact (I used the modality and had no impact or symptoms worsened)	Internal Family Systems therapy Slight	Internal Family Systems therapy Moderate	Internal Family Systems therapy Significant	Internal Family Systems therapy Very significant
Coaching/Spiritual Counseling	Coaching/Spiritual Counseling Not Applicable - Did not use this modality	Coaching/Spiritual Counseling No impact (I used the modality and had no impact or symptoms worsened)	Coaching/Spiritual Counseling Slight	Coaching/Spiritual Counseling Moderate	Coaching/Spiritual Counseling Significant	Coaching/Spiritual Counseling Very significant
Psychiatric Medications	Psychiatric Medications Not Applicable - Did not use this modality	Psychiatric Medications No impact (I used the modality and had no impact or symptoms worsened)	Psychiatric Medications Slight	Psychiatric Medications Moderate	Psychiatric Medications Significant	Psychiatric Medications Very significant
Reiki	Reiki Not Applicable - Did not use this modality	Reiki No impact (I used the modality and had no impact or symptoms worsened)	Reiki Slight	Reiki Moderate	Reiki Significant	Reiki Very significant
Accupuncture	Accupuncture Not Applicable - Did not use this modality	Accupuncture No impact (I used the modality and had no impact or symptoms worsened)	Accupuncture Slight	Accupuncture Moderate	Accupuncture Significant	Accupuncture Very significant
Yoga posture practice	Yoga posture practice Not Applicable - Did not use this modality	Yoga posture practice No impact (I used the modality and had no impact or symptoms worsened)	Yoga posture practice Slight	Yoga posture practice Moderate	Yoga posture practice Significant	Yoga posture practice Very significant
Breathwork practice	Breathwork practice Not Applicable - Did not use this modality	Breathwork practice No impact (I used the modality and had no impact or symptoms worsened)	Breathwork practice Slight	Breathwork practice Moderate	Breathwork practice Significant	Breathwork practice Very significant
Meditation practice	Meditation practice Not Applicable - Did not use this modality	Meditation practice No impact (I used the modality and had no impact or symptoms worsened)	Meditation practice Slight	Meditation practice Moderate	Meditation practice Significant	Meditation practice Very significant
Alcoholics Anonymous (or similar addiction therapy)	Alcoholics Anonymous (or similar addiction therapy) Not Applicable - Did not use this modality	Alcoholics Anonymous (or similar addiction therapy) No impact (I used the modality and had no impact or symptoms worsened)	Alcoholics Anonymous (or similar addiction therapy) Slight	Alcoholics Anonymous (or similar addiction therapy) Moderate	Alcoholics Anonymous (or similar addiction therapy) Significant	Alcoholics Anonymous (or similar addiction therapy) Very significant

Not Applicable - Did not use this modality

No impact (I used the modality and had no impact or symptoms worsened)

Slight

Moderate

Significant

Very significant

Talk therapy (CBT or DBT)

Talk therapy (CBT or DBT) Not Applicable - Did not use this modality

Talk therapy (CBT or DBT) No impact (I used the modality and had no impact or symptoms worsened)

Talk therapy (CBT or DBT) Slight

Talk therapy (CBT or DBT) Moderate

Talk therapy (CBT or DBT) Significant

Talk therapy (CBT or DBT) Very significant

EMDR

EMDR Not Applicable - Did not use this modality

EMDR No impact (I used the modality and had no impact or symptoms worsened)

EMDR Slight

EMDR Moderate

EMDR Significant

EMDR Very significant

Internal Family Systems therapy

Internal Family Systems therapy Not Applicable - Did not use this modality

Internal Family Systems therapy No impact (I used the modality and had no impact or symptoms worsened)

Internal Family Systems therapy Slight

Internal Family Systems therapy Moderate

Internal Family Systems therapy Significant

Internal Family Systems therapy Very significant

Coaching/Spiritual Counseling

Coaching/Spiritual Counseling Not Applicable - Did not use this modality

Coaching/Spiritual Counseling No impact (I used the modality and had no impact or symptoms worsened)

Coaching/Spiritual Counseling Slight

Coaching/Spiritual Counseling Moderate

Coaching/Spiritual Counseling Significant

Coaching/Spiritual Counseling Very significant

Psychiatric Medications

Psychiatric Medications Not Applicable - Did not use this modality

Psychiatric Medications No impact (I used the modality and had no impact or symptoms worsened)

Psychiatric Medications Slight

Psychiatric Medications Moderate

Psychiatric Medications Significant

Psychiatric Medications Very significant

Reiki

Reiki Not Applicable - Did not use this modality

Reiki No impact (I used the modality and had no impact or symptoms worsened)

Reiki Slight

Reiki Moderate

Reiki Significant

Reiki Very significant

Accupuncture

Accupuncture Not Applicable - Did not use this modality

Accupuncture No impact (I used the modality and had no impact or symptoms worsened)

Accupuncture Slight

Accupuncture Moderate

Accupuncture Significant

Accupuncture Very significant

Yoga posture practice

Yoga posture practice Not Applicable - Did not use this modality

Yoga posture practice No impact (I used the modality and had no impact or symptoms worsened)

Yoga posture practice Slight

Yoga posture practice Moderate

Yoga posture practice Significant

Yoga posture practice Very significant

Breathwork practice

Breathwork practice Not Applicable - Did not use this modality

Breathwork practice No impact (I used the modality and had no impact or symptoms worsened)

Breathwork practice Slight

Breathwork practice Moderate

Breathwork practice Significant

Breathwork practice Very significant

Meditation practice

Meditation practice Not Applicable - Did not use this modality

Meditation practice No impact (I used the modality and had no impact or symptoms worsened)

Meditation practice Slight

Meditation practice Moderate

Meditation practice Significant

Meditation practice Very significant

Alcoholics Anonymous (or similar addiction therapy)

Alcoholics Anonymous (or similar addiction therapy) Not Applicable - Did not use this modality

Alcoholics Anonymous (or similar addiction therapy) No impact (I used the modality and had no impact or symptoms worsened)

Alcoholics Anonymous (or similar addiction therapy) Slight

Alcoholics Anonymous (or similar addiction therapy) Moderate

Alcoholics Anonymous (or similar addiction therapy) Significant

Alcoholics Anonymous (or similar addiction therapy) Very significant

Pre & Post Program Symptom Questionnaire

Tell us about yourself:

Question Title

* 1. Participant Name

Question Title

* 2. Inner Alignment Program Start Date

Question Title

* 3. Healers providing Soul Retrievals during this program:
(Choose all that apply)

Question Title

* 4. Please share about your CURRENT USE of emotion-altering substance:

Question Title

* 5. Are you filling this Questionnaire out BEFORE your program, or AFTER you have finished the program?

Question Title

* 6. What modalities have you tried and provided a positive impact on your healing path in the last 5 years?

Pre & Post Program Symptom Questionnaire

Tell us about yourself:

Question Title

* 1. Participant Name

Question Title

* 2. Inner Alignment Program Start Date

Question Title

* 3. Healers providing Soul Retrievals during this program:(Choose all that apply)

Question Title

* 4. Please share about your CURRENT USE of emotion-altering substance:

Question Title

* 5. Are you filling this Questionnaire out BEFORE your program, or AFTER you have finished the program?

Question Title

* 6. What modalities have you tried and provided a positive impact on your healing path in the last 5 years?

* 3. Healers providing Soul Retrievals during this program:
(Choose all that apply)