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Christian Counseling Holistic Life Survey

Confidential — For personal and spiritual growth. Share with your counselor

"*" indicates required fields

A. PERSONAL & FAMILY BACKGROUND

Full Name*

Date of Birth*

MM slash DD slash YYYY

Age*

Gender*

Relationship Status*

Select Value

Single

Dating

Engaged

Married

Separated

Divorced

Widowed

Children (names & ages)

Where were you born and raised? What stands out most about your childhood?*

How would you describe your relationship with your parents or caregivers growing up?*

Are there any major family patterns (e.g., conflict, addiction, faith, divorce, poverty) that shaped you?*

Describe one memory that still feels painful or defining from your past.*

B. RELATIONSHIPS & COMMUNITY

How would you describe your current romantic or marital relationship?*

What do you find most fulfilling and most challenging about your relationship(s)?*

Who do you consider your closest friends, and how often do you spend time with them?*

Do you feel emotionally supported in your current circle of relationships? Why or why not?*

How do you usually handle conflict or misunderstanding?*

C. SPIRITUAL LIFE & FAITH JOURNEY

Describe your relationship with God at this point in your life.*

When did your faith first become personal or meaningful to you?*

What church or spiritual community do you currently attend (if any)?*

Which spiritual practices are part of your life (prayer, Scripture, fasting, service, worship, etc.)?*

Have you ever had a spiritual experience or encounter that marked you deeply?*

What doubts, questions, or frustrations do you currently have about God, the Church, or Christianity?*

What are your theological or denominational leanings (e.g., Pentecostal, Baptist, Catholic, Reformed, etc.)?*

D. EMOTIONAL & MENTAL HEALTH

How would you describe your overall emotional state these days?*

What emotions do you struggle to express or manage?*

Have you ever been diagnosed with a mental health condition or taken medication for it?*

Yes

No

If yes, please explain*

Do you experience anxiety, depression, intrusive thoughts, or trauma symptoms?*

What coping habits do you use when stressed (healthy or unhealthy)?*

E. PHYSICAL HEALTH & LIFESTYLE

How would you describe your physical health overall?*

Do you have any chronic illnesses, diseases, or physical limitations?*

What is your current sleep, nutrition, and exercise routine like?*

Do you use alcohol, tobacco, or other substances? How often?*

What foods, activities, or physical habits most affect your mood and energy*

F. WORK, MONEY & CALLING

What is your current job or career path?*

Do you feel called to your work or simply survive through it?*

How would you describe your relationship with money — fearful, responsible, impulsive, generous, etc.?*

What financial goals or struggles do you currently face?*

Who taught you about money growing up, and what messages did you receive about it?*

G. SEXUALITY & INTIMACY

What messages did you receive about sex and intimacy growing up?*

How would you describe your current sexual life — active, abstinent, struggling, fulfilled, ashamed, etc.?*

Have you ever experienced sexual trauma, guilt, or addiction?*

How do you view sexual purity, boundaries, and God’s design for intimacy?*

H. SOCIAL, POLITICAL & CULTURAL VIEWS

What social or political issues matter deeply to you, and why?*

How do your faith and values influence your political views?*

Do you feel tension between your beliefs and the culture around you?*

I. PERSONAL GROWTH & HABITS

What are your biggest strengths and weaknesses?*

What habits or addictions do you struggle with (e.g., food, social media, pornography, spending, control)?*

How do you recharge when you feel drained or overwhelmed?*

What hobbies, music, movies, or creative outlets bring you joy?*

What are your biggest pet peeves or triggers?*

J. DEEPEST HURTS & INNER HEALING

What past wounds still affect your present relationships or faith?*

Who do you still need to forgive — yourself or others?*

What lies or fears do you often battle in your mind?*

Where do you most desire healing or freedom right now?*

K. FUTURE DIRECTION & HOPE

If your life looked healthy and whole a year from now, what would be different?*

What legacy or impact do you want to leave behind?*

What are your top three goals for counseling or coaching?*

How can your counselor pray for you specifically?*

CAPTCHA

Location
(877) 237-8540
(305) 646-9894

Counseling & Wellness Team Available In-Person & Virtually 9am to 9pm Monday to Saturday By Appointment Only.
Schedule with Counseling Specialist Online or Contact Support Specialist

Support Team Available 9am to 6pm Monday to Saturday

SMS Support Number: (786) 550-2394

Need help? Message us on WhatsApp

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