Adult Assessment Tool
Shine Your Light, Christian Coaching & Consulting - Linda Sheppard, MS, FLE, PhD ABD
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Gender
*
Please Select
Female
Male
Transgender
Other
Prefer not to say
Age
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
*
Referred By:
*
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Presenting Problem
Describe the problem(s) that brings you to Shine Your Light?
*
Check any of the symptoms that you are having:
Depressed mood
Extreme sadness
Trouble concentrating
Memory problems
Change in eating habits
Feelings of extreme happiness
Trouble performing your job
Anger outburts
Self-esteem problems
Perfectionism
Obsessions or compulsions
Feels fearful
Physical complains of pain
Problems with anger
Thoughts of hurting yourself or others
Feeling hopeless
Feeling tearful
Change in sleeping habits
Lack of energy
Weight changes
Change in sexual interest or function
Problems getting along with friends or family
Feeling stressed
Easily irritated
Feeling guilty
Feeling nervous
Sudden feelings of panic
Muscle tension
Acting violently
Thoughts of killing yourself or others
History of Counseling
Have you even been in treatment before?
*
Please Select
Yes
No
If Yes, please give dates and the name of the person who saw for treatment
Was the treatment successful?
Please Select
Yes
No
What happened?
Have you been prescribed any psychiatric medications?
*
Please Select
Yes
No
If Yes, give the date and name of medication prescribed
Substance Abuse History
Do you or have you used:
*
Rows
Current Use
Past Use
Never Used
Comments
Tobacco (any form)
Alcohol
Caffeine (any form, including cola drinks)
Recreational drugs
Submit Assessment
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