Name
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First Name
Last Name
Preferred Pronouns
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Email
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Phone
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Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Birthdate
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Age
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Name
First Name
Last Name
Relationship to You
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What identities do you hold that you feel are important to who you are?
(i.e. cultural or ethnic groups, social identities, communities you belong to, etc.)
Challenging things from your history that you want me to know are:
Wonderful things from your history that you want me to know are:
Challenging things about your current life that you want me to know are:
Wonderful things about your current life that you want me to know are:
On a scale of 1 - 10, 10 = high, how would you rate the quality of your life today?
What is your biggest challenge(s) or obstacle(s) in life?
Describe what your life might look like if you successfully managed these challenges.
On a scale of 1-10, 10 = high, what is your current level of stress?
How do you typically deal with stress?
What do you find helps you when you're struggling?
How would you describe your overall health?
Do you have any current health concerns?
Are you taking any medications?
How would you describe your use of alcohol or other recreational drugs
Please describe your sleeping patterns.
Info may include if you feel well-rested upon waking, what time you go to bed, how many hours you sleep, nighttime rituals, dreams, or anything else you'd like to share.
Please describe your eating patterns and your relationship to food.
Info you may consider adding includes, how often you eat, when you eat, how your digestion is and if you experience any difficulties with appetite or eating.
On a scale of 1-10, 10 = high, how would you describe your daily energy levels?
Have you had any major hospitalizations?
Please include any hospitalizations for emotional reasons / mental health / major surgeries & share to the degree you feel comfortable.
What is your relational / marital status?
How would you describe your sexual orientation?
On a scale of 1-10, 10 = high, how would you rate your current primary relationship(s)?
Are there any repeating patterns that you would like to see change in your relationships? If so, please describe.
Do you have children? If so, describe.
Is there anything that feels important to share about your current living situation?
If currently employed, what is your current employment situation?
On a scale of 1-10, 10 = high, how much do you enjoy your work?
Is there anything stressful about your current work?
On a scale of 1-10, 10 = high, how satisfied are you with your financial health?
Are you currently involved or do you anticipate becoming involved in any legal proceedings?
Do you consider yourself to be spiritual or religious? If yes, please describe your belief or faith.
What do you consider to be some of your strengths?
What do you consider to be some of your weaknesses?
What do you value most in your life?
How can I best support you? What do you most need from me?
Is there anything else you’d like me to know?
