CHI Self-care Practice Survey

Creative Holistic Integration (CHI)

CHI Self-care Practice Form
The information you provide below will serve to support you as needed.
It will also serve to assess and improve the CHI program.
This information will remain confidential.

* Indicates required field

Name *

First

Last

Issue / Challenge *

Priority Technique *

Follow the Flow Chart and muscle test for Priority Technique.

Date of Practice *

Start time *

Finish Time *

Describe your experience: Include emotions, physical sensations, insights & comments. *

Before using Priority Technique: What number is your issue? *

0 Best 1 2 3 4 5 6 7 8 9 10 Worst

After using CHI Tool / Process: What number is your issue at now? *

Gender *

Female Male

What is your age? *

13-18 19-25 26-35 36-50 Over 50 Over 60 Over 70

Questions? Clarifications / Support needed? *

Submit

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