Please complete all questions. Your information is completely confidential and will not be shared. Please see our Privacy Policy. Web Site Personal details First name * Last name * Email address * Phone number * Your address * Address 2nd line Address 3rd line County Postcode Country * Country England Scotland Wales Northern Ireland (UK) Republic of Ireland United States of America ------------------------- Afghanistan Åland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (North) Korea (South) Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory (Occupied) Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Réunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin and Sint Maarten Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Do you have a partner? * Yes No Do you have dependants? * Yes No E.g. children or elderly parents. Age * Under 20 21–30 31–40 41–50 51–60 61–70 Over 70 Your Sun sign * Aries Taurus Gemini Cancer Leo Virgo Libra Scorpio Sagittarius Capricorn Aquarius Pisces Work life Do you work for a living? * Yes No Spiritual life Do you have any regular religious or spiritual practice? * Yes No Have you ever done any of Theolyn’s courses before? * Yes No Have you learnt any complementary therapies, (even if you do not practice as a therapist)? Yes No Do you receive any form of complementary therapy, such as reflexology or massage, other than for ongoing health issues? * Yes No Have you ever practiced any form of meditation? * Yes No Lifestyle How easy is your lifestyle at the moment? (5=very easy; 1=stressful) * 3 How would rate your overall feelings of wellness in the following areas? Spiritual — Sense of vitality for living is generally high (5) or low (1) * 3 Mental — Thoughts are focussed on the positive (5) or negative (1) * 3 Emotional — Relationships with people and the world are relaxed (5) or tense (1) * 3 Physical — You feel mostly comfortable (5) or uncomfortable (1) in your body * 3 Health Do you have any ongoing health issues? * Yes No You and Shefa What are you hoping to get from learning the Shefa Method? * Where did you hear about this course? * I subscribe to Theolyn.com From a friend Web search Via Facebook Magazine article Radio article Internet TV channel Other Having looked at details on the website, how far are you considering taking your Shefa training? (This doesn’t commit you to anything, it’s just an indication of your intentions) * I definitely don’t want to take it further Gateway Grade Luminary Grade Mastery Grade I haven’t made my mind up yet
