Coaching with Faatimah M - Assessment Form

Name

First NameLast Name

Age

Phone Number with Your Country Code

WhatsApp number.Format: (000) 000-0000.

Email

Place of residence

Your city and country

Occupation/Profession

Please share your current job role or how you usually spend your time (e.g. work, business, studying, homemaking, etc)

Please provide a brief summery of the main reasons you're seeking therapy?

AIMS AND WISHES. What do you want to change? Name up to three areas. A, B and C that you want to be better in?

Which of the following is important problems for you to solve in your life. Check as many boxes as you like.

AREAS OF STRENGTH. Indicate three personal strengths of yours which make you stand out positively, giving you a sense of pride. From any part of your life, professional or personal.

METHODS TRIED BEFORE. In previous efforts to move forward, what helped the most? Why do you think it worked?

BARRIERS OR STICKING POINTS. Can you describe what has been holding your progress back, if anything?

REASONS FOR THERAPY. Describe what parts of your life would be better if Allah granted your aims. Confidence, work, school, relationships, etc.

Optimistic about the future

Feeling close to Allah/ My faith is strong

Clear about my goals and direction in life

Relaxed and/or able to relax

I can think clearly

I can make up my mind about things

Feeling good about myself overall

Feeling cheerful

Able to deal with ups and downs

Satisfied with my connection to others

Feeling valuable and lovable for who I am

Able to laugh and enjoy good moments

Feeling focused and in control

Dealing with problems well

Glad to learn or experience new things

MEDICAL OR MENTAL HEALTH ISSUES. Medicines you take at the moment. Note only relevant treatments from other professionals, currently or in the past. Recall any diagnoses or other significant medical information related to your mental wellbeing. If none, state 'none'

Which package are you interested in

Sessions are non refundable.
1 Session — R950
3 Sessions — R2550
6 Sessions — R5000
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READINESS TO SHOW COMMITMENT. To move forward with this, would you sacrifice your time? Would you spend money? Would you be prepared to give up a bad habit? Explain how important this is to you and how committed you are on a scale of 1-10. 10 being very important and committed and 1 being not important and committed.

After submitting this application form, I will contact you via WhatsApp or email to schedule your sessions, In Sha Allah.