Assessment Questionnaire

Step 1 of 11

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Today's Date

MM slash DD slash YYYY

Your Name(Required)

First Last

Gender

Date of Birth

MM slash DD slash YYYY

Age

Religion

Email(Required)

Location

City State Zip Code

PRESENTING PROBLEM

1. Your reason for contacting CSCM.

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

3. Rate the intensity of this problem (1 being mild and 5 being most severe)

Mild	Moderate	Severe	Very Severe	Most Severe

4. How is this problem interfering with your daily functioning?

5. How is this problem interfering with your spiritual relationship internally?

6. How is this problem interfering with your relationship with the Heavenly Father?

7. What are your current goals, or outcomes for counseling?

8. How would your life be different if counseling is successful in helping you achieve your goals?

EMOTIONAL HEALTH

9. Please check all that apply to you now or in the last 30 days

Angry/Irritable

Have Special Powers

Recurring Nightmares

Anxiety

Avoidance

Can’t Be in Crowds

Can’t Concentrate

Depression

Easily Startled

Fatigue/No Energy

Feeling Nervous

Feeling Worthless

Fearful

Food or Eating Changes

Grief and Loss

Guilt

Lack of Interest

Hearing Things

Helpless

Hopeless

Impulsive

No Motivation

Not Hungry

No Need for Sleep

Panic Attacks

People Out to Get Me

People Watching Me

Poor Memory

Prefer Being Alone

Relationship Problems

Restless

Shame Sadness

Seeing Things

Self-Esteem Problems

Self-Harm

Sleep Changes

Too Little Sleep

Too Much Stress

Substance Use

Suicidal Thoughts

Suspicious

Thoughts of Dying

Flashbacks

Insomnia

10. What type of issues in your life would disturb your sleep?

11. Anything you would like to add?

SELF-MEANING

12. What do you consider your strengths?

13. What do you consider your weakness?

14. Do you remember the first time you were angry?

Yes

Share a little about it.

15. What was the last thing that made you really angry? Share a little about it.

16. Do you remember the first time you were hurt? If yes, share a little about it.

Yes

Share a little about it.

17. What is your first memory in life?

PERSONAL, FAMILY AND RELATIONSHIPS

18. Where were you born?

19. Were you raised there?

20. Who was your primary caregiver?

21. Was there a time when you had a primary caregiver who was not your biological caregiver? Share a little about it.

22. Is your Father living?

Yes

If deceased what impact did his death have on you?

23. On a scale of 1-5 with 5 being the highest, how would you describe your relationship with your father?

1	2	3	4	5

24. Is your Mother living?

Yes

If deceased what impact did his death have on you?

25. On a scale of 1-5 with 5 being the highest, how would you describe your relationship with your mother?

1	2	3	4	5

26. How many brothers do you have?

27. On a scale of 1-5 with 5 being the highest, how would you describe your relationship with your brother/s?

1	2	3	4	5

28. How many sisters do you have?

29. On a scale of 1-5 with 5 being the highest, how would you describe your relationship with your sister/s?

1	2	3	4	5

30. Any half brothers or sisters?

Yes

Please specify.

Which biological parent did you share with them?

31. Where are you in age order?

32. On a scale of 1-5 with 5 being the highest, how would you rate your relationship with your siblings while growing up?

1	2	3	4	5

33. On a scale of 1-5 with 5 being the highest, how would you rate your current relationship with your siblings?

1	2	3	4	5

34. Do you feel there was a favored child in your family? Share a little about it.

35. Did, or do you get along with that sibling(s)?

Yes

36. Is there any known family history of mental illness or substance abuse?

Yes

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

Yes

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

Yes

NOTE: If questions 40-43 are too personal in nature to answer, you can choose to answer in session, if desired.

39. Are you currently experiencing or has there been any problems with your family in the past (e.g., abuse, conflicts, stress, loss, etc)?(Required)

Yes

I prefer not to say

Please share a little about those problems. NOTE: you can choose to answer in session, if desired.

40. Have you ever spent time in a prison or corrections facility?

Yes

I prefer not to say

41. Do you consider yourself to be:(Required)

Heterosexual

Homosexual

Bisexual

Other

I prefer not to say

Name your sexual orientation here:(Required)

42. Has your sexual behavior ever led to involvement with the law?(Required)

Yes

I prefer not to say

43. Current marriage status?(Required)

Married

Divorced

Separated

Widowed

Never Married

44. How do you describe your relationship with your spouse?

Good	Fair	Poor	NA

How many marriages?

How many divorces have you been involved in?

Are you currently in a relationship?(Required)

Yes

How long?

Less than a month

1-6 months

1-3 years

3-5 years

6-10 years

Other

How do you describe your current relationship?

Good	Fair	Poor	NA

45. Do you have children?

Yes

Are they all living?

Yes

Sex and Ages of your Children

How do you describe your relationship with your children?

Good	Fair	Poor	NA

46. Any child custody or divorce issues?

Yes

Not Sure

47. Are you pregnant now?

Yes

Not Sure

If yes, when are you expecting?

48. Are you at risk for HIV/AIDS/Sexually Transmitted Diseases? (Unsafe Sex / Using Needles?)

Yes

49. Any food allergies?

SUBSTANCE ADUSE / ADDICITON

There is therefore now no condemnation for those who are in Yahoshua. For the law of the Spirit of life has set you free in Yahushua from the law of sin and death. Romans 8:1-2

50. Are you a current or former tobacco user?

Yes

What form(s) of tobacco have you used in the past?

Have you been in a program to help you quit using tobacco in the last 30-days?

Yes

NOTE: If questions 52-54 are too personal in nature to answer, you can choose to answer in session, if desired.

51. Would you or someone you know say you had a problem with alcohol use or addiction?(Required)

Yes

I prefer not to say

52. Would you or someone you know say you had a problem with pills or illegal drugs?(Required)

Yes

I prefer not to say

53. Is there a history in your family of addiction?(Required)

Yes

I prefer not to say

Please describe this in more detail. NOTE: you can choose to answer in session, if desired.

54. Have you ever been to a self-help group?(Required)

Yes

I prefer not to say

Please share a little about it. NOTE: you can choose to answer in session, if desired.

ABUSE HISTORY

NOTE: If questions 56-57 are too personal in nature to answer, you can choose to answer in session, if desired.

55. Have you been a victim of the following? Check all that apply.(Required)

Verbal

Physical

Emotional

Sexual

Neglect

Exploitation

I prefer no to say

56. Do you feel you are currently being abused? If yes, we will discuss during session.(Required)

Yes

I prefer not to say

57. Is there anyone in your life you have not forgiven?(Required)

Yes

I prefer not to say

If you could, would you forgive them?(Required)

Yes

Not Sure

58. Is there anyone in your life you need to ask them for forgiveness?(Required)

Yes

I prefer not to say

Do you feel they will forgive you?

Yes

Not Sure

EDUCATION, CURRENT WORK STATUS

59. Highest Education Attainment?

Elementary School

Middle School

High School

Vocational Training

Undergraduate Programs

Master's Programs

Professional Programs

Doctoral Programs

60. Are you a Veteran?

Yes

Which Branch?

What was your duty?

61. Are you currently employed?

Yes

Retired?

Yes

What was your occupation?

62. You ever had a problem holding a job?

Yes

63. Do you have any job-related problems?

Yes

64. School problems?

Yes

COUNSELING HISTORY

65. Are you currently, or within the last 60 days taken prescribed medication(s)?

Yes

66. Have you previously been to a counselor or psychiatrist?

Yes

67. During the last 6 months, have you thought of seriously hurting yourself or other people?

Yes

68. Have you ever attempted suicide?

Yes

69. Do you currently have plans to harm yourself?

Yes

70. During the last month, how often have you gotten out of the house to do things other than go to work, and taking care of necessities?

Never	Seldom	Often	Frequently

VIOLENCE AND TRAUMA

NOTE: If questions 72-78 are too personal in nature to answer, you can choose to answer in session, if desired.

71. Were you ever a victim of a violent crime?(Required)

Yes

I prefer not to say

How old were you when it happened?

72. Are you a victim of rape?(Required)

Yes

I prefer not to say

How old were you when it happened?

73. When you were a child, were you ever touched or fondled in a sexually inappropriate manner?(Required)

Yes

I prefer not to say

How old were you?

74. Were you ever made to touch/fondle someone in a sexual way?(Required)

Yes

I prefer not to say

How old were you?

75. Were you ever forced to have sex with your spouse/significant other?(Required)

Yes

I prefer not to say

76. Has anyone stalked you, in other words, followed you or kept track of your activities, causing you to feel intimidated or concerned for your safety?(Required)

Yes

I prefer not to say

77. Are you currently afraid of someone harming you?(Required)

Yes

I prefer not to say

MEDICAL/PAST MEDICAL/SURGICAL HISTORY

78. Are you experiencing any medical problems now?(Required)

Yes

I prefer not to say

Please explain.

79. List your past medications as best as you can.

80. Are you taking any medications currently and what are the dosages for each?

81. Have you ever been to a mental health professional before?(Required)

Yes

I prefer not to say

What was the reason?(Required)

82. Are you still going?(Required)

Yes

Why did you leave?(Required)

SPIRITUAL VIEWS

83. What do your friends, family, spouse think of you as being Torah Observant?

84. How would you describe the Ruach haQodesh (Holy Spirit)?

85. “As I move towards Yah/Yahuah/Yahweh, He begins to rest in me.” What does this statement mean to you?

86. What importance does your faith, belief, or spirituality have in your life?(Required)

87. On a scale of 0 (not important at all) to 5 (extremely important), how you would rate the importance of faith, belief, or spirituality in your life?(Required)

Very Unimportant	Unimporant	Neutral	Important	Very Important

88. Have your beliefs influenced you in how you handle stress?(Required)

Yes

89. What role do your beliefs play in your health care decision making?

90. Are you part of a spiritual or religious community?(Required)

Yes

Share a little about it such as the name of your religious community, how long you’ve been there, what you like or dislike about it, if you have plans to leave or remain there.

91. Is this community supportive to you?(Required)

Yes

How? Please explain.(Required)

92. Is there a group of people you really love or who are important to you?(Required)

Yes

If yes, share a little about it.

93. Do you have spiritual beliefs or Bible verses that help you cope with stress?

Yes

Please share a little about this.

94. On a scale of 1-5 where 5 is the highest how would you describe your relationship to Yahuah/Yahweh.

1	2	3	4	5

95. On a scale of 1-5 where 5 is the highest where do you place your prayer life?

1	2	3	4	5

96. On a scale of 1-5 where 5 is the highest how faithful are you to reading your Bible.

1	2	3	4	5

97. What comes to mind when you think of Soul Care?

98. Of which denomination(s) were you raised? If several list them all from earliest to latest.

99. As an adult, how often do you attend services?

Never	Rarely	Fairly Often	Not Much	Regulary

100. When you were coming up as a child, did both parents attend church?

Yes

Not Sure

Anything you would like to add?

PRESENTING PROBLEM

EMOTIONAL HEALTH

SELF-MEANING

PERSONAL, FAMILY AND RELATIONSHIPS

NOTE: If questions 40-43 are too personal in nature to answer, you can choose to answer in session, if desired.

SUBSTANCE ADUSE / ADDICITON

NOTE: If questions 52-54 are too personal in nature to answer, you can choose to answer in session, if desired.

ABUSE HISTORY

NOTE: If questions 56-57 are too personal in nature to answer, you can choose to answer in session, if desired.

EDUCATION, CURRENT WORK STATUS

COUNSELING HISTORY

VIOLENCE AND TRAUMA

NOTE: If questions 72-78 are too personal in nature to answer, you can choose to answer in session, if desired.

MEDICAL/PAST MEDICAL/SURGICAL HISTORY

SPIRITUAL VIEWS

Thank you for taking the time to fill out these necessary questions. Your healing journey has begun.

Ready to get started?

LATEST BLOG POST

Spiritual Abuse Part 3 Continued

By Sister Diane November 8, 2023

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