Therapy 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.

Which of the following are concerns for you? (Check as many as applicable)

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”)

Optimistic about the future

Feeling close to Allah/ My faith is strong

Clear about my goals and direction in life

Able to trust Allah’s plan

Feeling at peace with myself

Feeling valuable and worthy of Allah’s love

Able to deal with life’s ups and downs

Enjoying life and being present in the moment

Able to identify Allahs love, mercy etc

Afraid of Allah, punishment, anger etc

Feeling focused

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.

Coaching with Faatimah M

Assessment Form