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Questionnaire for private holistic consultation meeting
Confidential (for support and understanding only)
Full Name
*
(as you’d like it displayed)
Age:
Preferred contact method
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Email
Phone
Email Address
Phone
Occupation (if applicable):
Relationship status:
Select
Single
Married
Divorced
Separated
In a Relationship
Engaged
Domestic Partnership
Civil Union
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Do you have children?
Yes
No
If yes, how many and ages?
What brings you to counselling at this time?
How long have you been experiencing this concern?
How is it currently affecting your daily life, relationships, or emotions?
How would you describe your mood lately (anxious, low, hopeful, etc.)?
Do you often feel overwhelmed, stuck, or disconnected?
Have you experienced major life changes recently (grief, separation, illness, etc.)?
What helps you cope when you feel stressed or emotional?
Do you have supportive people in your life you can talk to?
Have you had counselling or therapy before?
What would you like to gain or change through Holistic consultation?
Are there specific areas you’d like to explore (e.g., self-confidence, relationships, anxiety)?
Is there anything you’d like me to know before we begin?
Are you on medication?
Yes
No
If Yes what medication is it and Please describe your medical condition as well?
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