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Welcome to the blog website of Anne Heffron: writer, mother, adoptee.

The Unofficial Official 93-Day Intake Form for Adoptees and People Who Needed Better Mirroring

The Unofficial Official 93-Day Intake Form for Adoptees and People Who Needed Better Mirroring

Welcome to the 93-Day Clinic. Please fill in the following to the best of your ability. When rating on a scale from 1 to 10, 1 is what you consider to be nearly unbearable and 10 is what you consider to be ideal.

Thank you for your time. 

Please keep this in your file. We will repeat this procedure in 93 days to witness the glory of intentional transformation. 

Settle in. This might take a while.

Your answers matter. 

1.    Age

2.    Weight

3.    Height

4.    Age at relinquishment

5.    Number of foster homes you (attended?)

6.    Age you were first (taken in?) by your adoptive parents

7.    Amount of money you have in a savings account

8.    Number of times you have been married

9.    Are you in recovery? If so, for what substance(s)

10.  Do you have habits others might call addictions? Please list

11.  Do you have contact with your biological mother

12.  If yes, describe relationship with one word

13.  Do you have contact with your biological father

14.  If yes, describe relationship with one word

15.  Tell us in a sentence what being adopted means to you

16.  Describe your relationship with your (adoptive) parents in a few sentences

17.  What are your main health concerns

18.  Have you ever received psychiatric treatment

19.  If yes, how was it helpful/not helpful

20.  Have you ever suffered from depression

21.  On a scale from 1-10, how would you rate yourself as a human being

22.  List physical symptoms (aches/pains/something just feels wrong) you have but that you don’t talk about

23.  List three more

24.  Now the one you think will get you called crazy or neurotic

25.  Are you the person you think you were born to be

26.  Do you have health insurance

27.  How much money do you estimate you have spent on health issues, mental and physical, as an adult

28.  Do you have nicely formed feces on a daily basis that go into the toilet with a satisfying plop so cleanly that you could almost skip wiping

29.  What did you eat yesterday

30.  Are you comfortable with your diet

31.  Are you comfortable with your home life

32.  Are you comfortable with your work

33.  Are you comfortable with your social life

34.  Please explain if you answered no to any of the above

35.  On a scale from 1-10, rate your general ability to focus on a task

36.  How many hours do you generally sleep at night

37.  Are you lonely

38.  Are you high

39.  Are you yourself

40.  Do you want to get high? Why

41.  What gets in the way of major life goals

42.  Do you have major life goals you are proud of and what are they

43.  How do you express yourself creatively

44.  What do many people not know about you

45.  Are you proud of yourself

46.  Please write a sample of your internal dialogue of what it sounds like when your brain talks about you and your strengths and weaknesses

47.  Please rate your general anxiety level from 1-20. I mean 10

48.  When you look in the mirror, what relatives do you see

49.  Do you have siblings, biological or adoptive? What is your relationship with them? How is their health

50. On a scale from 1-10 how much do you love yourself

51. How well do you feel your brain works on a scale from 1-10

52. Does your brain feel foggy? If so, what percent on the time

53. Do you have to talk yourself out of bed every morning or do you wake up happy

54. How many times a day do you think about adoption

55. Do you feel like you live in mud or water or some other substance

56. How many people do you have in your life who you feel really know you

57. If you are not your ideal person now, describe how you would like to be

 

Please remember to stay hydrated and to not text and drive.

 

If you send me your answers (anneheffron@gmail.com), I won't show them or talk about them specifically to anyone. I'll just read them, learn from them, and keep them for you so we can compare your before and after answers at the end of the 93 days. 

 

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