Willow Ann Rose LPC CHT ~ SpiritWell
PO Box 42114
Eugene, OR 97404
Phone: 541 461-5424


The information you provide will be kept confidential as outlined in privacy and confidentiality guidelines set
out in state and federal regulations. Please see my “Professional Disclosures” document for summary of
these guidelines. Feel free to add any other information you feel may be useful. We will review this
information and together, create a plan of services that will best support your personal goals. Please contact
me with any concerns prior to completing this questionnaire or ask questions at any point in our work.


* Indicates Required Fields

* Name: * Birthdate: 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
* Home/Mailing Address: * City * State * Zip
* May I send correspondence here? Yes    No   
* Telephone Number(s):
Best number for contact? What type of message may I leave?
* Local Emergency Contact: * Phone:
Relationship to You?
How Were You Referred to Me?
* Best email address to contact you:


* Briefly describe what brings you to therapy.
* List symptoms/behaviors/situation(s) most concerning to you.
* How long have you considered engaging with these issues?
* What prompted the contact now?
* What are your goals for therapy and how will you know our work is helping?
* What would you like to change, feel differently about?
* What feels within your power to change?
* What nourishes you? What do you do for fun?
* Describe your strengths.
* Briefly describe your spiritual or religious beliefs or the basic ethical guidelines that inform your
life. If you were raised with a different belief system, what was it?
* Do you engage in a daily meditation, spiritual or prayer practice?
* What activities, practices bring you feelings of Peace? Or Equanimity? Or Hope?
* What leads you to smile?
* Have you ever experienced an NDE (near death experience)?
* Have you ever experienced a “peak or mystical experience” or an experience that was
“strange” or difficult to describe/explain?
* Are you currently in a primary relationship? If so, note duration, and briefly describe the quality
of this relationship.
* If you have shared other significant partnered relationships, please provide a brief history.
* Who lives in your household? (Number of people/ages/relationships.) Please include animal companions.
* How do you feel about this arrangement?
* Do you have children? Ages and where do they reside?
* How would you describe your circle of friends? In what ways and how often do you connect?
* Please 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?
* Daily caffeine intake?
* Describe your sleep:
* Are there ways in which you engage in body/physical exercise/movement practices? What kind? How often?
* Do you smoke cigarettes? How many per day?
* Please list current Medications/Supplements/Herbal Medicines:
Include CBD and other such products.
* If used and comfortable disclosing on this form, also include recreational and sacramental medicines.
* Prescriber(s)
* Please list any other health care practitioners, counselors or agencies you are currently working with.
* Do you have any history for addictions or alcohol/substance abuse?
* If applicable, describe current use: substance(s), amount, and frequency.
* Any recent changes in use, amount or frequency?
* Have you experienced, or are you currently experiencing: mental, emotional, physical or sexual abuse?
* Would you describe yourself as an activist and/or “first responder”?
Yes    No
* Are you a veteran, a survivor of an armed conflict or natural catastrophe?
Yes    No
* Please briefly describe as much as you are comfortable at this time.
* Previous Counseling? If so, 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? Please briefly describe.

* Did you complete High School or Equivalent education?
* Did you attend College or Vocational Trainings?
* What was your “school/training” experience like for you?
* Easiest or the most challenging?
* What is your current occupation?
* Previous jobs or vocations?
* What was your favorite job/activity?
* Your least favorite? (Consider paid and/or volunteer positions.)
* Current daily responsibilities: employment/school/home tasks?
* How do you feel about your ability to manage these tasks?
Anything you would like to change?
What is your energy like at the end of your day?
* Briefly Describe Your Family of Origin.
* Please indicate if you have siblings younger or older than yourself.
Where were you raised?
In a few words describe your “home” environment.
Any relevant factors that particularly informed your upbringing?
Include: race, culture, ethnicity, religion or strong family beliefs.
Note any family history for addictions or mental illness.
Was there a family member you feel or felt the closest to?
Least close?
Have you experienced loss or death of a significant family member?
Yes    No
If so, how old were you?
Feel Free to Offer Additional Information:
I may offer or suggest a variety of approaches and modalities to best support your goals. It is
essential to me that I offer strategies that honor, respect and support your spiritual, religious,
cultural and traditional beliefs. I will also offer specific modalities at your request and if we
decide a particular strategy may be of benefit to you. It will always be your choice to decide
which modalities you are interested in working with.

Listed below are the basic modality descriptors for the therapeutic pathways I currently offer.
There are many varieties of strategies under each of these labels. At this time, please put a
check next to the modalities that you would like to engage in or further discuss.
Additional Information is available on the website: www.spirit-well.com

Transpersonal~Integrative Psychotherapy
Mindfulness~Contemplative Practices
Transpersonal Hypnotherapy
Spiritual Regression (Within Life~Past Life~Between Lives)
Spirit Path Medicines~Shamanic Practices
Subtle Energy Medicines
“Soul Blossoming~Embodied Soul Midwifery” Spiritual Mentoring~Coaching

*Today's Date

You will receive an email of your questionnaire. Please be sure your email address is correct above.

Form Revised July 2020