client-data-sheet 2

Instructions for bottom section:

MYCS provider: (your name)

Date: (date form completed)

# of sessions: this will be “0” for the pre survey and 1-? for post survey. Write how many times you met and used MYCS.

Dx: diagnoses (anxiety, depression etc) the client has already been given

DISC: their disc score. (Ex: Ds/c)

Key element: for post survey. This is the item you or they feel created the most change for them

Pre and post survey: for post survey, stating how many times they average stopping to love themselves or connect with their authentic self

Absence of reaction since: for pre and post survey, how long (days or hours) since they have had a negative limbic reaction, outburst, panic attack, etc

Longest span w/o reaction: for pre and post survey, what’s the longest period of time they have gone without a negative limbic reaction

Submitted date: (date you send form to MYCS)

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