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Questionnaire

Amy Beltaine, MDiv

Accredited Spiritual Director, Minister

Portland, OR  503-877-2692

amybeltaine.com

abeltaine@gmail.com

CLIENT QUESTIONNAIRE

The information you provide will be kept confidential. Feel free to add any other information you feel may be useful. We will review this information and together, create a plan of services that will best support your personal goals. Please contact me with any concerns prior to completing this questionnaire.

 

Name_______________________________________________________Birthdate_____________Age___________

Mailing Address_________________________________________________City____________________________

Zip_____________May I send correspondence here?____________

Telephone Numbers for: Home:________________________Cell:_______________________

Message phone or email:___________________________________

Local Emergency Contact  (Name)_____________________________(Phone)________________________

High School Diploma?________GED?________Highest degree earned:_______________________________

Current profession/vocation_______________________________________________________________________

Employer ____________________________________

Sexual orientation:  Heterosexual________Gay_______Lesbian_______Bisexual ___________

Gender Identity: ________________Other ID___________________(What pronouns do you prefer?)

I am currently:

Single___Married____Divorced______Separated_____Domestic Partnered_____Other_____________

How Were You Referred to Me? _________________________________________________________________

Who Lives in Your Household? (First names & relationship to you) _________________________________________________________________________________________________________

Currently in a Primary Relationship? If so, note duration, and briefly describe the quality of this relationship  _________________________________________________________________________________________________________

Children? Gender/Ages and Where Do They Reside? ________________________________________________________________________________________________________

Briefly Describe Your Family Of Origin. Please indicate if you have siblings younger or older than yourself; who raised you and where; any relevant cultural/religious factors that particularly informed your upbringing. _________________________________________________________________________________________________________

Describe your personal strengths _________________________________________________________________________________________________________

How would you describe your circle of friends? _________________________________________________

How would you describe your religious/spiritual community? ________________________________________________________________________________________________________

Please describe any spiritual practices or beliefs that sustain you: _________________________________________________________________________________________________________

How would you describe the most sacred/holy for you? 

_________________________________________________________________________________________________________

Is your life a journey? Dance? Painting? Describe the scenery, colors, smells, feelings...

_________________________________________________________________________________________________________

What is your purpose/goal/hope in life?

_________________________________________________________________________________________________________

What is your earliest memory of thinking about that which is greater than you/the holy/your purpose/vision/hope?

_________________________________________________________________________________________________________

What nourishes you? What do you do for fun?

_______________________________________________________________________________________________________

Please list current health concerns and history for significant accidents, surgeries, illness or medical hospitalizations:

_________________________________________________________________________________________________________

How would you describe your current nutritional choices? _________________________________________________________________________________________________________

Describe your sleep ______________________________________________________________________________

Your daily caffeine intake?_____________ Do you smoke? What and how often?__________________

What kind of exercise do you get? How often?____________________________________________________

What are your favorite stress management strategies? (Activities, places, hobbies, etc.) _________________________________________________________________________________________________________

Please list current Medications/Supplements/Herbs:__________________________________________ _________________________________________________________________________________________________________

Do you have any history for addictions or alcohol/substance abuse? __________________________

What is your current use?  _________________________________________________________________________

Do you have any history of physical, sexual, or ritual abuse?  Are you a survivor of an armed conflict or natural catastrophe?            Please describe:

_________________________________________________________________________________________________________

Have you ever experienced suicidal thoughts/feelings or actions? Please describe:

________________________________________________________________________________________________________

Previous Spiritual Direction? Briefly describe. What was helpful/not helpful? _________________________________________________________________________________________________________

Please List Other Agencies/Counselors/Practitioners Currently Involved With:

_________________________________________________________________________________________________________

What draws you to the idea of spiritual direction? Why now?

_________________________________________________________________________________________________________

Describe your goals/expectations for our work together: _________________________________________________________________________________________________________

How will you know our time together is helping? _________________________________________________________________________________________________________

As specifically as you can, describe how you will know you have completed the goals you have listed? _________________________________________________________________________________________________________

Is there anything else you would like me to know at this time?

_________________________________________________________________________________________________________

 

Of the Tools I Offer, Please Circle the Type(s) You are Most Interested In:

Song      Mandalas, collage, and artwork            Prayer bracelets/rosary

Journaling      Movement work             Enneagram            Runes     

Meyers Briggs personality profile      Dialog            Tarot            Dream work     

Guided visualization       Spiritual Types      Lectio Divina (reading sacred words)

 

 

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                  Client Signature                                                                           Today’s Date

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