Coaching with Faatimah M - Assessment Form

Coaching with Faatimah M
Assessment Form
Name*

First NameLast Name
Age*
Phone Number*
WhatsApp number.
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.*

Feeling sad/depressedGrief and lossObsession, was-was or other repetitive habits and thoughtsAddiction (anything from phone, food, alcohol, smoking, etc)Relationships with othersProblems with faith/ Deen, or purpose in lifeAchieve aims or intentionsDirection or knowledge about what to do in lifePoor habits or conductBad decisions or choicesConfidenceTrauma or abuseGender or sexual preferenceDiet, weight and similar issuesAnger managementAnxiety, worry or fearsOppressive or abusive environment
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*

NeverOnly a littleSometimesQuite a lotAll the time
Feeling close to Allah/ My faith is strong*

NeverOnly a littleSometimesQuite a lotAll the time
Clear about my goals and direction in life*

NeverOnly a littleSometimesQuite a lotAll the time
Relaxed and/or able to relax*

NeverOnly a littleSometimesQuite a lotAll the time
I can think clearly*

NeverOnly a littleSometimesQuite a lotAll the time
I can make up my mind about things*

NeverOnly a littleSometimesQuite a lotAll the time
Feeling good about myself overall*

NeverOnly a littleSometimesQuite a lotAll the time
Feeling cheerful*

NeverOnly a littleSometimesQuite a lotAll the time
Able to deal with ups and downs*

NeverOnly a littleSometimesQuite a lotAll the time
Satisfied with my connection to others*

NeverOnly a littleSometimesQuite a lotAll the time
Feeling valuable and lovable for who I am*

NeverOnly a littleSometimesQuite a lotAll the time
Able to laugh and enjoy good moments*

NeverOnly a littleSometimesQuite a lotAll the time
Feeling focused and in control*

NeverOnly a littleSometimesQuite a lotAll the time
Dealing with problems well*

NeverOnly a littleSometimesQuite a lotAll the time
Glad to learn or experience new things*

NeverOnly a littleSometimesQuite a lotAll the time
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*

3 Sessions6 Sessions10 Sessions
Sessions are non refundable.
3 Sessions — R2400
6 Sessions — R4600
10 Sessions — R7500
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I understand that Faatimah does not provide Emergency or crisis therapy services
I understand that there are no "quick fix" solutions and in order to fully benefit from these session I am committed to playing full out.
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. *
I understand that sessions are NON- REFUNDABLE and rescheduling is available upto 24 hrs before the appointment after 24 hrs the session will be forfeited unless it’s due to total emergency.By submitting this form, you acknowledge and agree to these terms.
After submitting this application form, I will contact you via WhatsApp or email to schedule your sessions, In Sha Allah.
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