Finding Your Way Questionnaire

Important Note:  Please answer the following 3 questions. If you answer YES
to any of them, then online counseling is NOT appropriate for you at this time. 

* Indicates a required field. Limited fields below.

(1) Are you currently having any serious thoughts about committing suicide?
If so, please stop reading right now.  Call your local suicide hotline by
dialing 911, or go directly to your local hospital’s emergency room.  
*

(2) Are you in the midst of a serious emotional crisis right now? If so,
I suggest that you contact a mental health professional in your local area.
*

(3) Do you have serious or intense emotional problems? If so,
I suggest that you contact a mental health professional in your local area.
*

(4) Are you under 18 years old?  If so, I would need written consent
of a parent or guardian in order to work with you.  
*


Instructions: Please fill out this questionnaire and return it to me. 
Please read the Spiritual Direction Informed Consent Form first before
you fill out the questionnaire. 

  *First Name:

*Last Name:

*Gender:
*Age:

*Birth Date:
(01-01-1990)

Day:

Month:

  

Year:

*Marital Status:

*Occupation:

*Employment:

*Home Address:

*City:

*State:

*Zip or Postal Code:

Province:

*Country:

*Home Phone 
(for emergency purposes only):

*Work Phone 
(for emergency purposes only):

*Email Address:

*Confirm Email Address:



Please Note: Take all the space you need. The boxes below will expand.

1.  What has prompted you to seek spiritual direction at this point in time?
2.  Why are you interested in online spiritual direction rather than traditional face-to-face spiritual direction at this point?
3.  Have you ever been in treatment with a therapist or counselor in the past? If so, when  and for what problem(s)? What was the result of this? Is a therapist, counselor or psychiatrist treating you at this time?
4.  What do you know about spiritual direction and what are you seeking from it?.
5.  With what organized religions have you participated? How would you describe yourself with regard to your religious/spiritual orientation? Are you currently affiliated with any denomination or group?
6.  What concept do you have of G-d or some higher power, if any?
7.  What conflicts and/or questions do you seek answers for with regard to religion/spirituality?
8.  Are you currently taking any psychotropic medication? (e.g., anti-depressants or anti-anxiety medication) Do you drink alcoholic beverages? If so, how much, how often and what kind(s)? Do you use illegal drugs? If so, how much, how often and what kind(s)? 
9.  Please describe your current living situation. In what type of home do you live and with whom?
10.  If you are married or have a "significant other" or long-term partner, what is that person's name? How long have you been together? Please describe your relationship and the quality of that relationship.
11.  Do you have any children? If so, what are their names and ages?
12.  Do you have any brothers or sisters? Where are you in the sibling order? (e.g., oldest, middle, youngest) Where do they live and how do you get along with them?:
13.  Are your parents alive? Where do they live and how do you get along with them? 
14.  Do you have in-laws? Where do they live and how do you get along with them?
15.  How much education have you completed?
16.  If you are a student now, what school are you attending? What grades are you earning? How do you feel about your education? What is your major?


17.   Are you happy with your current job/career? If not, why? What jobs/careers have you done in the past and how did you like them?
18.  How would you describe your state of physical health? Do you have any medical problems now or in the past that would be helpful for me to know about?
19.  Is there anything else about you that I should know?
20.  How did you find out about Finding Your Way, Inc.? What search engine or keywords did you use?

Important Note: By returning this questionnaire, I acknowledge that I have read the Spiritual Direction Informed Consent Form and agree with all of the terms and conditions stated therein.