Psychospiritual Evaluation Form Psychospiritual Evaluation Form Alias * Age * Email * Country Location Gender At Birth Who were your primary caretakers? Put a check mark beside your level of education * Less Than High School High School Some College College Degree Graduate Degree My mother/maternal caregiver was raised in a: Upper Class Middle Class Lower Class My father/paternal caregiver was raised in a: Upper Class Middle Class Lower Class *For the following questions: ‘religious refers to being a part of an organized religion where an external God(s) is/are upheld and external laws conformed to. By ‘spiritual’ we mean being guided from within. * My mother/maternal caregiver was Religious Spiritual Neither My father/paternal caregiver was Religious Spiritual Neither I am Religious Spiritual Neither Did your parents divorce/separate? Yes No If So, How Old Were You? Were either of your parents (caretakers) addicted to any drugs? Male Female Number of siblings you were raised with: Your birth order: Were you abused emotionally, verbally, physically, sexually by anyone? By whom, when and for how long? Give a brief description of any other significant traumas you experienced: I was hugged OFTEN as a child. Yes No I heard “I love you” OFTEN as a child. Yes No Did either of your parents drink? Often Heavily Very Rarely Never Drank Did either of your parents hit you? Occasionally (3x a year) Often (weekly) Heavily (belt, wooden spoon, etc) Very Rarely (3x during childhood) Never Complete this Sentence Completion, “I had a difficult childhood because...” How would you describe the relationship you had with your mother/maternal caregiver? How would you describe the relationship with your father/paternal caregiver? What are the most outstanding memories about your mother/maternal caregiver? What are the most outstanding memories about your father/paternal caregiver? How would you describe yourself? (Include all the following in your description; success, failures, aspirations/goals, fears and intentions). Are you presently being treated by a doctor/medical therapist/counselor? Yes No If so, please elaborate Check mark all that relates to you. I am always broke I am Unemployed I am fearful I am stressed out I choose to be happy right now. I am uncertain of life’s meaning and purpose I do not know what to believe about me I do not know what to believe about others I have difficulty forming healthy relationships I think I am always taken advantage of. I am afraid to say ‘no’ I see the best in others. I trust others until they prove to be untrustworthy I do not think others respect me. Life is fulfilling I love my job I hate my job I feel that I need more out of life, but I am not sure what I need. I am depressed I am anxious I lie to myself I had emotionally abusive parents I have a good relationship with my partner. I need to experience personal growth. I seek more personal recognition I have had numerous Marriages (how many?) I have poor temper control My sex life is unsatisfactory I am ashamed of who I am I do not find pleasure in anything I do I find pleasure in most things I do I have difficulty communicating how I feel I am afraid to communicate my feelings to others I need more authority I am afraid to love I am often let down by others People take advantage of me Within the last three years I have been divorced Within the last three years I filed bankruptcy Within the last three years I have experienced the death of a loved one I am a highly functional depressive. I have an eating disorder I am addicted to alcohol/other. I seek a soul mate I seek more spiritual growth I follow through with most things I set out to do. I withdraw vs confronting others I do not get along with my peers. Anything else you would like us to know? Why are you seeking coaching currently? What are your goals and objectives regarding coaching? How did you hear about us? Submit
