Psychospiritual Evaluation Form

Psychospiritual Evaluation Form
Put a check mark beside your level of education *
My mother/maternal caregiver was raised in a:
My father/paternal caregiver was raised in a:

*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
My father/paternal caregiver was
I am
Did your parents divorce/separate?
Were either of your parents (caretakers) addicted to any drugs?
I was hugged OFTEN as a child.
I heard “I love you” OFTEN as a child.
Did either of your parents drink?
Did either of your parents hit you?
Are you presently being treated by a doctor/medical therapist/counselor?
Check mark all that relates to you.

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