Assessment Questionnaire (PREVIEW FOR DIANE)

Date

SECTION 1: TELL A LITTLE ABOUT YOURSELF

Name

First Last

Sex

Male

Female

Date of Birth

Age

Please enter a number from 10 to 100.

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Phone

SECTION 2: CURRENT CONCERNS

What is your reason for contacting CSCM?

How long have you or your loved one been experiencing this problem?

Rate the intensity of this problem.

Mild	Severe	Most Severe

How is this problem interfering with your spiritual health regarding your relationship with Yahuah?

How would your life be different if counseling is successful?

SECTION 3: EMOTIONAL PROBLEMS, CONFLICTS, AND CONDITIONS

Please check all that apply

	Past	Present
Avoidance
Bitterness
Thoughts of Suicide
Depression
Complacency
Divorce
Hopelessness
Doubt
Unbelief
Grief
Fear
Profanity
Resentment
Self-Sabotage
Anxiety
Abortion
Wayward Thoughts
Unforgiveness
Rage

Add ANY emotion(s) if it is not listed here.

SECTION 4: SENSE OF SELF

What do you consider your strengths?

What do you consider your weakness?

Do you remember your first memory in life?

SECTION 5: YOUR FAMILY

Share a little about who raised you (blood parents, stepparents, grandparents) and the quality of care they gave you.

List the ages of your blood brothers. Which ones do you get along with the most and which the least? We will discuss more in session if needed.

List the ages of your blood sisters. Which ones do you get along with the most and which the least? We will discuss more in session if needed.

Where are you in age order?

Any half brothers or sisters?

Yes

None

Which ones do you get along with the most and which the least? We will discuss more in session if needed.

Do you feel there was a favored child in your family? Could you share a little about it?

Has there been or is there now any known family history of mental illness or substance abuse?

Yes

None

Please share a little about it. If you prefer, this can be discussed in session.

Were there any cultural and/or social issues that impacted your childhood? For instance, poverty, discrimination, oppression of any sort?

Can you say that you grew up in a dysfunctional (broken/maladjusted) home?

Yes

Please share a little about it. If you prefer this can be discussed in session.

Have you ever spent time in jail or prison?

Yes

Please share a little about it. If you prefer this can be discussed in session.

SECTION 6: HABITS & DEPENDENCIES

Would you or someone you know say you have had a problem with alcohol, pills, or illegal drugs?

Yes

Would you or someone you know say you have or had a problem with sexual immorality (pornography, adultery, fornication, incest, inordinate sexual lust, inordinate attraction to the same sex)

Yes

Prefer not to say

Please identify and speak briefly about it. If you prefer, this can be discussed in session.

Is there a family history of any of these dependencies or addictions listed above?

Yes

Please share a little about it. If you prefer, this can be discussed in session.

SECTION 7: TRAUMATIC EVENTS

Please share any other traumatic event(s) that have significantly impacted your life. Are you currently afraid of someone harming you?

Are you or have you ever been a victim of abuse? Please share. Include your age at the time of the event. Again, if you prefer, this can be discussed in session.

Is there anyone in your life you have not forgiven?

Yes

Not Sure

If you had the opportunity, would you forgive them?

Yes

Not Sure

Is there anyone in your life you would like to ask forgiveness?

Yes

Not Sure

Do you feel they would forgive you?

Yes

Not Sure

SECTION 8: EDUCATION & CAREER

Highest Education Attained.

Did you retire from the military?

If you are a veteran, please enter the branch you served.

What is your current employment status?

Employed

Unemployed

Seeking Employment

Laid Off

Retired

SECTION 9: MEDICAL HISTORY

When was your last medical exam?

Do you have any known medical conditions?

SECTION 10: SPIRITUAL BELIEFS AND VALUES

What do your friends, and or, family, think of you as being Torah Observant?

Have you been baptized?

Yes

How would you describe your relationship with the Ruach haQodesh (Holy Spirit)?

Explain what this statement means to you. “As I learn to live in Yah/Yahuah/Yahweh, I REST IN HIM.”

Have your spiritual beliefs influenced how you handle stress? Please explain.

Share two of your favorite Bible verses.

Describe your prayer life.

Good	Fair	Need Work

Describe your bible study.

Good	Fair	Need Work

If applicable, in which denominations were you raised? List from earliest to current.

How did you learn about Compassionate Soul Care Ministry?

What keywords did you use?

Is there anything else you would like to add?

MY CONFIDENTIALITY STATEMENT TO YOU

I, Diane Foster, owner of Compassionate Soul Care Ministry (CSCM) upholds the following statement:

We are committed to keeping your information private. However, confidentiality is not absolute, and we may be required by law to disclose information if there is an imminent risk of harm to yourself or others, if abuse or neglect of a child, elderly person, or vulnerable adult is suspected, or if we receive a lawful court order requiring disclosure.

Diane Foster, Founder, Compassionate Soul Care Ministry (CSCM)

DATED: October 06, 2026

SECTION 1: TELL A LITTLE ABOUT YOURSELF

SECTION 2: CURRENT CONCERNS

SECTION 3: EMOTIONAL PROBLEMS, CONFLICTS, AND CONDITIONS

SECTION 4: SENSE OF SELF

SECTION 5: YOUR FAMILY

SECTION 6: HABITS & DEPENDENCIES

SECTION 7: TRAUMATIC EVENTS

SECTION 8: EDUCATION & CAREER

SECTION 9: MEDICAL HISTORY

SECTION 10: SPIRITUAL BELIEFS AND VALUES

I, Diane Foster, owner of Compassionate Soul Care Ministry (CSCM) upholds the following statement:

To Begin Your Healing Journey

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