This questionnaire in an editable format will be emailed to you once an appointment is arranged
<< All the information in this questionnaire will be kept private and confidential >>
Date of Birth:
Emergency Contact Name:
Emergency Contact Phone Number:
☐ Single ☐Living Together ☐Married ☐ Widowed ☐ Separated / Divorced
What is your present employment and area of work?
If you had access to $10 million, what would you love to do for work?
Please describe any serious illnesses, accidents, or injuries
Please list any medication that you are currently taking and for what aim
Indicate any drugs you use
☐Alcohol ☐Nicotine ☐Marijuana ☐Psychedelics ☐Opiates ☐Amphetamines ☐Other
Frequency of use
Mental Health Information
Are you currently in counselling elsewhere? ☐Yes ☐No
Have you had previous counselling? ☐Yes. ☐No
Rate each area of your life 1 – poor 5 - Average 10 – great
Financial 1 2 3 4 5 6 7 8 9 10
Vocational 1 2 3 4 5 6 7 8 9 10
Familiar 1 2 3 4 5 6 7 8 9 10
Social 1 2 3 4 5 6 7 8 9 10
Spiritual 1 2 3 4 5 6 7 8 9 10
Mental 1 2 3 4 5 6 7 8 9 10
Physical 1 2 3 4 5 6 7 8 9 10
A few questions now to help to determine your unique hierarchy of Values
1. How do you fill your personal space?
Have you ever noticed how things that are really not important to you go into the trash, the attic, or the storage closet? By contrast, you keep the things that are important to you where you can see them, either at home or at work.
What does your life demonstrate through your space? When you look around your home or office, do you see family photos, sports trophies, business awards, books? Do you see beautiful objects, comfortable furniture for friends to sit on, or souvenirs of favorite places you’ve visited? Perhaps your space is full of games, puzzles, DVDs, CDs, or other forms of entertainment. Whatever you see around you is a very strong clue as to what you value most.
What 3 things fill your space?
2. How do you spend your time?
Here’s something you can count on: people always make time for things that are really important to them and run out of time for things that aren’t. Even though people usually say, “I don’t have time for what really I want to do,” the truth is that they are too busy doing what is truly most important to them. And what they think they want to be doing isn’t really what’s most important. You always find time for things that are really important to you. Somehow, you figure it out. So how do you spend your time? What do you always find time to do? How you spend your time tells you what matters to you most.
In which three ways do you spend your time?
3. How do you spend your energy?
You always have energy for things that inspire you – the things you value most. You run out of energy for things that don’t. Things that are low among your values drain you; things that are high among your values energize you. In fact, when you are doing something that you value highly, you have more energy at the end of the day than when you started because you’re doing something that you love and are inspired by. So how do you spend your energy – and where do you get your energy?
In which three ways do you spend your energy and where do you feel energized?
4. How do you spend your money?
Again, you always find money for things that are valuable to you, but you never want to part with your money for things that are not important to you. So your choices about spending money tell you a great deal about what you value most. Now, at this point, you might be noticing some overlap: some similarities between what you fill your space with and how you spend your time, energy, and money. That is healthy. It means that you have already aligned a lot of your values, goals, and daily activities. If you notice a lot of divergence between the answers to these first four questions, you might benefit from bringing your values and goals into deeper alignment.
In which three ways do you spend your money? What do you always find money for?
Now on to some further questions.
What are 3 things you most like about yourself?
What are 3 things you most resent about yourself?
Consider these questions –
Who do you perceive is running your life or burdening you the most?
Who do you perceive is pushing your buttons the most?
Who do you perceive you would least like to be around?
Who do you resent or despise the most?
Who do you infatuate with, admire, or attract to the most?
Who do you feel ‘incomplete’ with?
Who do you perceive as ‘hurting’ or ‘hooking’ you?
Who do you feel left, abandoned, or dumped you?
Who are you having difficulty loving and would love to love more?
Who do you desire to feel more love for?
Who do you have the most emotional charge on in your life?
What do you perceive is missing in your life?
What are you currently most stressed and worried about?
Please describe your personal struggles and concerns and the reasons that you are seeking help at this time.
List in order the 3 highest priority things you would change if you could.
What do you feel your most limiting beliefs and blocks are? (Write as much as you like and as best as you can describe what comes up)
Please say a little about what you hope to achieve from our consults.
What else would you like me know?
Thank you for taking the time to fill this out, it will help me make sure we work on the highest priority areas during our time together.