Therapy with Faatimah M - Assessment Form

Coaching with Faatimah M
Assessment Form
Name*

First NameLast Name
Age*
Phone Number*
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 short summary of what has brought you to seek spiritual coaching.*
AIMS AND WISHES. What do you hope to change or improve? Name up to three areas (A, B, and C) that you would like to work on.*
Feeling spiritually disconnectedStruggling with faith in Allah's planFeeling overwhelmed by guilt or past mistakesDifficulty in trusting Allah or making du'āConfusion about the purpose of lifeStruggling with consistency in ibadah (prayer, dhikr, etc.)Anxiety, worries, or fears related to spiritualityStruggling with self-worth or self-acceptanceHealing from trauma or past emotional woundsOvercoming cultural or family expectations in faithStrengthening tawakkul (trust in Allah)Finding peace in difficult circumstancesUnderstanding Allah’s mercy and loveBuilding confidence in decision-makingOther
AREAS OF STRENGTH. List three personal strengths that make you feel proud or confident in your personal or spiritual life.*
METHODS TRIED BEFORE. What have you tried before to strengthen your connection with Allah? What worked well for you?*
BARRIERS OR STICKING POINTS. What has held you back from making progress in your spiritual journey?*
How would your life improve if you reached your spiritual goals?(For example: “I would feel more at peace,” “I would have clarity in my decisions,” “I would feel closer to Allah”)*
NeverOnly a littleSometimesQuite a lotAll the time
NeverOnly a littleSometimesQuite a lotAll the time
NeverOnly a littleSometimesQuite a lotAll the time
NeverOnly a littleSometimesQuite a lotAll the time
NeverOnly a littleSometimesQuite a lotAll the time
NeverOnly a littleSometimesQuite a lotAll the time
NeverOnly a littleSometimesQuite a lotAll the time
NeverOnly a littleSometimesQuite a lotAll the time
NeverOnly a littleSometimesQuite a lotAll the time
NeverOnly a littleSometimesQuite a lotAll the time
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'*
1 Session3 Sessions6 Sessions
Sessions are non refundable.
1 Session — R950
3 Sessions — R2550
6 Sessions — R5000
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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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Coaching with Faatimah M

Assessment Form