Support Staff Private

[v. 03-06-2019, 5 A.M.] Interim page now private for NIHA staffer, Laurie, and anyone she wants to share it with. This page likely will soon be removed from the menu in order to keep it private, so Bookmark the URL.
New Staffer, this page is planned to hold information that will help you when you speak with people about what I offer to them. An earlier version was once titled "Pepper Communications Page."

This first worksheet was from a practitioner whose interview by David Van Nuys, Ph.D., was impressive. I have not reviewed it recently.
C.A.R.E.S.S. worksheet to help reduce behavior that is hard to control. CARESS = Communicate Alternatively; Release Endorphins; Self-Soothe.
[Click here to download PDF]

Tell It To The Duck -- Worksheet with pictures
[Click here to download PDF]

Below are links as of July 14 2015 from the Helpful Forms Menu item. Click here for most up to date forms.

If you're a new client, ask me about the following forms. [Quick link to Extra documents below.]

Signature Instructions:

1. Distance clients: To sign digitally, download and read the documents, then attach them to an email containing your name and date and Subject: Signature.
Please remember that this is not an encrypted communication system.

2. In-Office clients: You may use the same process as in #1. Or, you may print and bring these with you to the office at the time of your appointment.

Main Set:

Patient Assessment Form- PAF" (helpful for international consultations): PDF version | RTF version | MS Word version

"Coaching Assessment Form- CAF" (helpful for international consultations): PDF version | RTF version | MS Word version

Informed Consent for consultation or coaching with Dr. Wilson:

Informed Consent [PDF]

Informed Consent [MS Word]

Informed Consent for Counseling [PDF]

Informed Consent for Counseling [MS Word]

Informed Consent for Coaching [PDF]

Informed Consent for Coachling [MS Word]

[Additional commentary page on this site: Informed Consent]

Notice of Privacy Practices: Download [PDF]

Arbitration Agreement: [PDF]

No Self-Harm Contract: 
PDF version | MS Word version

Iridology Forms Set -- for Focused Iridology Appointments and Research option

"Patient Assessment Form- PAF" (helpful for international consultations): PDF version | MS Word version

Informed Consent [PDF]

Informed Consent [MS Word]

Notice of Privacy Practices: Download [PDF]

In addition, if you have been referred by an outside physician or clinic for Focused Iridology appointment, please read this statement: I provide iris photogaphy and iridology assessment as part of a larger framework of interpretation. I also require the above forms (PAF and Informed Consent) so that I can be assured that I have the best opportunity to discover what is called "the root cause" of a person's concern about health of body or mind. You are invited to read more about Iridology Science on my Information Site [click here].

Amen Clinics Forms:


  • Adult Intake, FemalePDF format [Contains sections: Adult Intake questionnaires , Psychiatric and Medical History, Amen Adult General Symptom Checklist, Amen Brain System Checklist, Amen Learning Disability Screening Questionnaire, Female Hormone Health Questionnaire, Medical Review Checklist, Neuropsychiatric Symptom Checklist, Amen Clinic Brain SPECT Informed Consent Form]


  • Adult Intake, MalePDF format [Contains sections: Adult Intake questionnaires , Psychiatric and Medical History, Amen Adult General Symptom Checklist, Amen Brain System Checklist, Amen Learning Disability Screening Questionnaire, Male Hormone Health Questionnaire, Medical Review Checklist, Neuropsychiatric Symptom Checklist, Amen Clinic Brain SPECT Informed Consent Form]
  • Amen Clinics Referral from Dr. Wilson -- Reston VA clinic [PDF format]
  • Amen Clinics Referral Nationally or Overseas [PDF format]

Stephen Porges, Ph.D. form:

Body Perception Questionnaire -- "...The BODY PERCEPTION QUESTIONNARIE has five sub-tests: 1) Awareness, 2) Stress
Response, 3) Autonomic Nervous System Reactivity, 4) Stress Style, and 5) Health History Inventory [PDF formatHis site.


Pre-consultation Lab Testing with International testing option [more]

NuPathways PAK QuestionnairePDF version | RTF version | MS Word version

"Psychometabolic Questionnaire" from WholePsychiatry.comPDF version | RTF version | MS Word version

Sleep Medicine information re Sleep and ApneaEpworth Sleepiness Scale | Berlin Questionnaire [PDF]

If you are a Veteran [Note to families: Please be sure your Veteran knows this]:
VA Health Care and the Affordable Care Act

If you are a Veteran who isn't enjoying the benefits of VA health care enrollment, please apply for VA health care. You may apply online at: You can also visit your local VA halth care facility. Or, call 877-222-VETS (8387) to apply by phone.

Affordable Care Act considerations: You can download this document that describes your current benefits and reassures with the following text: "How is my VA health care coverage affected?" ANS: Nothing in the health law changes your VA care benefits. You can continue to use VA for all of your health care needs or complement your VA care with private health insurance or coverage by other federal health care programs, including Medicare, Medicaid and TRICARE.
Download Full Document of Frequently Asked Questions about VA Health Care: Click Here -- PDF

Extra Information:

Advanced Directive Support -- Visitation: Wallet card and information for family, supporting Dr. Wilson visiting you in Hospital, Hospice or Home visits. [View PDF]

Essays and Informative documents:

Dr. Stephen Porges: "How Your Nervous System Sabotages Your Ability to Relate" [View PDF]

FlexAware Fitness/Neuro-Structural Rehab support [PDF format]:
"Create My FlexAware Habit" | FlexAware Self-Assessment Log

Your Health Menu: Insights about planning for your next choices in health care [View PDF

This next section is about the very important area of Sexual Health and Wholeness. 

1. DC Advocacy Partners graduate Kali Wasenko is co-founder of Their internet site, social media and events are impressive when you use a search engine for Kali Wasenko and AbleDate. I am planning on sending an invitation to her and her partner to learn more about the Acupuncture and Chinese Medicine insights of therapist Felice Dunas, Ph.D. See below. DC Advocacy Parters [ site ] is part of the Institute for Educational Leadership [ site ].  
Announcement of AbleDate workshop in August 2015: [link] Contact information: "For more information, contact Andres Urbina or Kali Wasenko at (305) 608-9528 or [email protected].
2. Dr. Dunas is a Los Angeles therapist. [] I learned about her work in 2005 while developing my own professional approach to functional integration of body/mind/emotions/relationships. I consider her insights to be very substantial as benefiting women especially in topics that I as a man cannot directly experience. 

Kristle I think that you would gain a lot of we could arrange for her to teach in the DC area, possibly to coincide with the Psychotherapy Networker Symposium 2016. I would like to develop Wisdom Day 2016 to include a Venue for her to teach about Acupuncture, Chinese Medicine maybe also Yoga or Movement and Healing Through Pleasure. (Even if a person has disabilities they deserve Pleasure.)

Healing Through Pleasure with Dr. Dunas

Healing through pleasure emphasizes the benefits happiness and comfort can bring to all areas of life - from medical to professional to personal. A 40 year veteran of ancient Chinese principles, Dr. Dunas uses her understanding of human behavior and the human body to enhance the lives of individuals, couples and corporate executives through pleasurable means.

Here is information about the Shrink Rap Radio psychology podcast. [site]

This link [interview 208, Pre- and Peri-Natal Psychology with William Emerson, Ph.D.] leads to an introductory page that brought your family situation to my mind:

William R. Emerson, Ph.D., is a renowned workshop leader, writer, lecturer, and pioneer in the field of pre and perinatal psychology. He is among the first in the world to develop prenatal and perinatal treatment methods for infants and children, is an expert in treatment methods for adults, and is recognized world-wide for his contributions. He is also co-president of APPPAH, the Association for Prenatal and Perinatal Psychology and Health, and has been on the Board of Directors for twenty years. He is the author of six books, five self-published, the co-author of Remembering Our Home , and the author of 15 published chapters and journal articles in the field of pre and perinatal psychology. He is also the writer and producer of four video programs. He holds graduate degrees from Vanderbilt and San Jose State Universities, graduating with honors. He has held university appointments as Honorary Faculty, Director of Clinical Training, International Lecturer, and Assistant Professor of Psychology. As an acknowledgment of his contributions to psychology, he received an honorary fellowship from the National Institute of Mental Health. Dr. Emerson practiced psychotherapy for 25 years, specializing in psychotherapy and regression therapy for infants, children, and adults, and lectured domestically and internationally on these topics. Dr. Emerson is retired from the practice of psychotherapy and is currently writing a book on spirit and soul wounding, finishing a book entitled: The Dark Side of Childbirth and Its Effects on our Children (Stonebrook Press, June 09), and conducting open workshops and training programs in the U.S., Canada, Mexico, and Europe.

you might be interested to know that his wife is Dr. Myrtle Heery who I interviewed on Shrink Rap Radio #115 about Humanistic-Existential Psychotherapy.

Also, as I mentioned in the interview, a good companion piece is the interview I did with Dr. Tony Madrid on Shrink Rap Radio #119 – Using Hypnosis and EMDR to Repair Broken Maternal/Infant Bonds.