Form 2. Client Questionnaire

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Document #4

Client Questionnaire

Willow Ann Rose LPC CHT ~ SpiritWell
PO Box 42114 – Eugene, Oregon 97404
www.spirit-well.com

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Name*

First Middle Last

Birthdate*

Current Age*

Is there a name you prefer I call you?

If comfortable, please share your pronouns:

she/her

he/him

they/them

ze/hir

Other

Please specify*

Home Address*

If different, Your Mailing Address*

Telephone Number/s*

Best Number for Contact*

Voicemail Available?*

Yes

Local Emergency Contact*

Name

Phone No. or Best way to contact*

Relationship to you*

How Were You Referred to Me*

Best Email adress to contact you*

Briefly describe what has called you to our meeting.*

List symptoms/behaviors/situation(s) most concerning to you.*

How long have you considered working with these issues?*

Why now?*

What would you like to be different?*

What change do you hope to notice first?*

What feels within your power to change?*

What nourishes you? What brings you a smile?*

Describe your strengths.*

Briefly describe your spiritual, philosophical or religious beliefs or the basic ethical guidelines that inform your life.*

Are your current beliefs different from how you were raised?*

Do you engage daily in any forms of meditation, spiritual practice, prayer?*

What brings you Peace? Equanimity? Hope?*

What guides you to feel grounded, aware in the present moment?*

Have you ever experienced*

an NDE (near death experience)

a Peak or Mystical Experience

a Spiritual Awakening

an experience that was strange or difficult to describe or explain

If so, describe

Are you currently in a "primary" relationship(s)?*

Yes

If so, note the duration and briefly describe the quality/form of this relationship(s).*

Who lives in your household?*

People/Ages/Relationships. Please include animal companions.

How do you feel about this arrangement?*

Do you have children?*

Yes

What are their ages? Where do they reside?*

Age/Residence

How would you describe your circle of friends? In what ways and how often do you connect?*

Briefly list current health concerns, locations of chronic pain and history, dates for significant accidents, surgeries, illness or medical hospitalizations.*

How would you describe your current nutritional choices?*

How is your sleep? Do you recall your dreams?*

What kinds of movement or exercise do you engage in? How often?*

Please list current RX medications, Supplements, Herbal Medicines and their purpose:*

Name/Purpose

List

If comfortable, include CBD and other such products:

Prescribers:*

Other healthcare practitioners, counselors, or agencies you are currently working with?*

Yes

If so, please list

Do you carry history for addictive substances or behaviors?*

Yes

Currently "use or struggle"?*

Yes

Family members with similar history/struggle?*

Yes

If used, and comfortable disclosing, please note recreational and sacramental medicines

Have you experienced, or are you currently experiencing mental, emotional, physical, or sexual abuse?*

Are you a First Responder, survivor of an armed conflict or natural catastrophe, activist?*

First Responder

Survivor of an armed conflict

Survivor of natural catastrophe

Activist

Do you identify as a member of a lineage that has been targeted based on culture, race, religion, gender, sex, age, body, etc.*

Yes

If so, briefly describe as much as you are comfortable at this time.

Previous Counseling?*

Yes

If yes, approximate date(s)/age(s) and briefly describe.

Include Psychiatric Hospitalizations and Alcohol/Drug Programs

What was helpful or not helpful about the counselor, method, or facility?

Have you ever experienced suicidal thoughts/ feelings or actions?*

Yes

If so, please briefly describe.

Did you complete High School or equivalent education?*

Yes

Attend College or Vocation Trainings?*

Yes

What was your "school/training" experience like for you?*

Easiest or the most challenging part?

Current Occupation*

Previous jobs or vocations

What was your favorite job/activity?*

Your least favorite? (Consider paid and/or volunteer positions)*

Describe your daily responsiblities.*

Employment, school, and home tasks

How do you feel about your ability to manage these tasks?*

What is your energy like at the end of your day?*

Briefly describe your "Family of Origin" and/or those who raised you:*

Siblings younger or older than yourself?*

Any relevant factors that particularly informed your upbringing? Include country/place, race, culture, religion, or strong family beliefs:*

Is there a family member you feel or have felt the closest to?*

Yes

If so, please specify

Is there a family member you feel or have felt the least close to?*

Yes

If so, please specify

Have you experienced loss or death of a significant family member?*

Yes

If so, how old were you?

Is there other information you feel called to offer at this time?

I may offer or suggest a variety of approaches and modalities to best support your goals. Please feel free to request additional information and ask questions.

It is important that I offer practices that honor, respect and support your spiritual, religious, cultural and traditional beliefs and will be of most benefit to you. It will always be your choice to decide which modalities call to you or not.

Signature*

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Today's Date*

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