Spiritual Intake Form

Please complete this form to the best of your ability.

NOTE: It is best to complete this form using either a laptop or desktop on Chrome Web Browser.
Should you run into issues please try and clear your web browser and/or contact us HERE

Spiritual Intake Form (#16)

Trinity Psych Wellness

SPIRITUAL INTAKE FORM

For Therapy and Empowerment

First Name

Last Name

Today's Date

Date of Birth (Day/Month/year)

Section One

Personal and Spiritual Background

What is your religious or spiritual background (if any)?

Do you currently follow any spiritual or religious practices? If yes, please describe.

What does spirituality mean to you personally?

Are there any particular spiritual or religious beliefs that are especially important to you?

Do you participate in any community, group, or religious gatherings?

How has your spirituality or religion influenced your life decisions, relationships, or sense of purpose?

Section Two

Current Spiritual Practices

Do you engage in any of the following practices? (Check all that apply)

Meditation

Prayer

Mindfulness

Journaling

Rituals (e.g., seasonal, praying, fasting, or cultural)

Any other practices not included above?

How often do you engage in the above practices?

Do you have a personal spiritual routine or discipline?

Are you interested in exploring or developing new spiritual practices? If yes what are you interested in?

Section Three

Spiritual Challenges and Growth

Are there any current challenges you are facing in your spiritual journey?

Have you experienced any major life events that have influenced your spiritual path?

Do you feel any conflicts between your spiritual beliefs and other aspects of your life (e.g., work, family, relationships)

What areas of your life do you feel need healing or empowerment?

Section Four

Therapeutic Goals and Empowerment

What are your goals for therapy or empowerment work?

How would you like your spirituality to be integrated into your therapy sessions?

What would spiritual empowerment look like for you?

Section Five

Additional Information

Is there anything else about your spiritual or religious beliefs that you think would be helpful for me to know?

Are there any spiritual or cultural sensitivities I should be aware of?