Name Cartography Institute
Pre-Assessment Questionnaire — Form NC-1
Complete before your appointment. There are no wrong answers. Some questions have no good answers.
Part I — Basic Information
Legal name (current): ____________________________
Date of birth: ____________________________
Age at time of assessment: ____________________________
Number of prior assessments at this or any affiliated Institute: ______
Languages in which you have been named (list all, including languages you no longer speak): ____________________________
Part II — Name History
These questions are to help your technician contextualize the map. You may leave any question blank.
Approximately how many distinct names or forms of address do you believe you have been called throughout your life? (Include nicknames, childhood diminutives, names used by a single person, names you were called in error and did not correct.) ______
Of these, how many do you believe were given with significant affection or care? ______
Of these, how many do you believe were given with the intention to diminish or harm? ______
Are there names you were called that you no longer wish to have assessed or identified? [ ] Yes [ ] No
Note: The scan records all marks regardless of preference. This question affects only whether the technician will name marks aloud during the session.
Have you been called by a name that belonged to someone else — a family member, a deceased person, a historical figure? [ ] Yes [ ] No
Have you ever been called a name that you did not recognize as applying to you? [ ] Yes [ ] No
Part III — Preparation
Have you prepared yourself to see marks from persons who are deceased? [ ] Yes [ ] No [ ] Uncertain
Have you prepared yourself to see marks you cannot identify? [ ] Yes [ ] No [ ] Uncertain
Have you prepared yourself to see marks in locations that surprise you? [ ] Yes [ ] No [ ] Uncertain
Is there a specific mark or region of the map you are most hoping to understand?
____________________________
Is there a specific mark or region of the map you are most afraid to see?
____________________________
Part IV — After the Assessment
The Institute offers post-assessment counseling for patients who find the results distressing or who wish to discuss findings with a practitioner. Would you like information about this service? [ ] Yes [ ] No
I understand that the Name Map records all marks present at the time of assessment and that no mark can be removed, altered, or rendered invisible by any current procedure.
Signature: ____________________________
Date: ____________________________
Form NC-1. Name Cartography Institute, Standard Pre-Assessment Documentation.
Please return this form to the front desk before your scheduled appointment time.
They almost always look at the back one first.
— handwritten, initials illegible