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Surveys
2015
March
C
Client Questionnaire
Client Questionnaire
0%
Exit Survey
Hello:
You are invited to participate in our questionnaire. In this questionnaire people will be asked to answer questions about themselves. It will take approximately 15 -20 minutes to complete the questionnaire.
Your participation in this questionnaire is completely voluntary but it will allow me to review your answers prior to your visit with me. There are no foreseeable risks associated with this questionnaire, it will provide me some insight on your concerns However, if you feel uncomfortable answering any questions, you can hold off until we meet in present. It is very important for me to learn and understand the reason for your visit.
Your questionnaire responses and every appointment with me will be strictly confidential. Your information will remain confidential. If you have questions at any time about the questionnaire, you may contact me via phone and/or email at the email.
Thank you very much for your time. Please start with the survey now by clicking on the
Continue
button below.
How would you classify your current situation?
Normal
Chaotic
Rut
Evolving
Upside down
Okay
What is the main reason for your visit?
Personal
Financial
Health
Love
Family
Spiritual
How often are you concerned with your current situation?
Daily
Weekly
Often
All the time
Never
If you could change anything in your life, what would it be?
Appearance
Employment
Relationship
Health concerns
I would not change anything
Everything
What can bring a change to your current situation?
Relocate
Change job
Relationship
Finances
Organization
Freedom
What can bring a change to your life?
Health
Finances
Employment
Relationship
Family
Do you have any big transitions currently taking place in your life?
Yes
No
Not sure
Do you have any current dependencies?
Relationship
Family
Children
Drugs
Other dependencies
What is your current employment status?
Employed full-time
Employed part-time
Not employed
Leave of absence
Other
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