Counselling Assessment FormPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name or Pseudonym *Age *GenderMaleFemaleOtherContact No *Email *Occupation *What is the primary reason you are seeking counseling at this time? *On a scale of 1–10, how much is this issue impacting your daily life? Selected Value: 0(1 = Minimal, 10 = Severe)Have you previously attended counseling? *YesNoIf yes, what did you find most or least helpful?Are you currently taking any medications? *YesNoSleep Quality *PoorOkayGood Contact did you Exercise Frequency *Rarely1-2x week+3+ weekDo you meditate? *YesNoTried before, don't do nowSubstance Use: (Alcohol, Tobacco, others) *YesNo, neverSometimeHow big is your social circle? *BigFew close friendsDon't have close friendsWhat are few specific goals you hope to achieve psychologically and physically within yourself? *What do you believe is your greatest strength? *Submit