Chronic Illness Spiritual Counseling Intake
Personal Information
Full Name
Date of Birth
Email
Phone Number
Address
Health Information
Chronic Illness Diagnosis
How long have you been living with this diagnosis?
Current Treatments/Medications
Other Relevant Health Conditions
Spiritual Background & Preferences
Describe your spiritual or religious background
Current Spiritual Practices (if any)
What kind of spiritual support are you seeking?
Emotional & Psychological Wellbeing
How are you feeling emotionally at this time?
Coping Strategies you currently use
Mental Health History
Goals and Expectations
What do you hope to gain from spiritual counseling?
Any concerns or questions?