This Questionnaire is designed to provide information that will assist your counselor in understanding your unique needs. In completing it, kindly be guided by total openness and honesty, as this will influence the total outcome of your interaction with your counselor. Be assured that any information provided on this sheet and any other place during and in the course of your interaction with your counselor, would be treated with the utmost confidentiality.
If one of your parents is not alive, kindly provide the following information
On a Scale of 1 – 10, with 1 being Very Poor, 10 being Extremely Well and 5 being It’s-Alright, rank your relationship with regards to the following indices (as it is, not wish-could-be)
On a scale of 1 – 10, with 1 being a Burden, 10 being a Blessing and 5 being It’s-Alright, rank your relationship with regards to the meeting or satisfaction of the following (as it is, not wish-could-be)
I hereby declare and agree that the information provided above to my best of knowledge is accurate and true and shall form the basis for this and any subsequent counselling sessions with PG Sebastian Coaching unless otherwise advised. I agree that the information provided herein shall be deemed confidential and shall not be used or divulged to any other person not affiliated to PG Sebastian Coaching for any purpose without my prior notice.