Name *

First Name

Last Name

Financial problems *

Severe

Moderate

Mild

None

Physical health and/or handicap *

Severe

Moderate

Mild

None

Misuse of drugs or alcohol *

Severe

Moderate

Mild

None

Problems associated with eating *

Severe

Moderate

Mild

None

Spiritual concerns *

Severe

Moderate

Mild

None

Feelings of depression or sadness *

Severe

Moderate

Mild

None

Thoughts of suicide *

Severe

Moderate

Mild

None

Feelings of anxiety or nervousness *

Severe

Moderate

Mild

None

Sexual concerns *

Severe

Moderate

Mild

None

Problems with parents and self *

Severe

Moderate

Mild

None

Parenting concerns *

Severe

Moderate

Mild

None

Threatened or actual abuse/violence *

Severe

Moderate

Mild

None

Boundary violation by a professional *

Severe

Moderate

Mild

None

Problems associated with aging *

Severe

Moderate

Mild

None

Anger or problems with temper *

Severe

Moderate

Mild

None

Unusual fears *

Severe

Moderate

Mild

None

Job stress *

Severe

Moderate

Mild

None

Feelings of loneliness *

Severe

Moderate

Mild

None

Compulsive behaviors *

Severe

Moderate

Mild

None

Issues around childlessness *

Severe

Moderate

Mild

None

Relationship problems *

Severe

Moderate

Mild

None

Trouble relating to others *

Severe

Moderate

Mild

None

Lack of self-confidence *

Severe

Moderate

Mild

None

Body image issues *

Severe

Moderate

Mild

None

Other (if yes, provide additional details below) *

Severe

Moderate

Mild

None

How serious are your present concern(s)? *

Not at all

Mildly

Moderate

High Priority

How serious are you in resolving your concern(s)? *

Not at all

Mildly

Moderate

High priority

How optimistic are you that your concern(s) can be resolved? *

Not at all

Mildly

Moderate

High priority