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Clinical Consultation Screening
Please answer the following questions in order for me to learn more about you, your experience with Clinical Providers, your Growth Potential needs/wants, and how Clinical Consultation could benefit you.
1.
In general, how would you rate your overall Mental Emotional Health & Wellbeing?
Excellent
Very good
Good
Fair
Poor
2.
What area of your life are you most interested in pursuing & cultivating your Growth Potential?
Cultivating Positive, Health Relationships (family, social, professional)
More effectively manage Anxiety
More effectively manage Depression and/or Self Doubt
Cultivate a Strategic Plan for my Growth Potential
Desire to improve daily living habits/routines
Desire to enhance motivation/drive/accomplishment
Desire to hone in on Success Habits
Managing Stress
Identifying Coping Skills
Desire to increase my SelfAwareness
Desire to cultivate a mindfulness practice
Desire to enhance my Clinical Professional Development
Other (please specify)
3.
Have you ever sought formal Mental Health Counseling before?
Yes
If yes, when was your last appt. and what was the presenting issue?
No
No, but I have always wanted to
Please provide any additional information about prior care that may be helpful:
4.
Have you ever been hospitalized and/or on Medication for a mental health issue, such as Depression, Anxiety, Suicidal Ideation, Self Injurious behaviors, Homicidal Ideations, Post Partum Rage?
Yes
Yes, in the last year
No
No, but probably should have
Other (please specify)
5.
If you've ever engaged in formal Mental Health treatment, what wasn't helpful? What did you wish was different?
The provider's personality
Their style of Feedback
Accessibility of Service
Their Technique/Strategy
Homework Assignments
Follow up Tasks
Measuring Progress
Other
6.
If you could have access to personalized, convenient Professional Coaching/Clinical Guidance what area would you be most interested in (Choose your top 2)?
Personal Life
Professional Life
Lifestyle (habits, routines, mindfulness, overall wellness goals)
Organization
Strategic Planning for your life
7.
What are your best days or times of contact for consultation and/or sessions?
Monday- Friday
Saturday
Sunday
Mornings
Midday
Afternoons
Evenings
Varies based on travel schedule
8.
Are you feeling motivated to cultivate a strategic plan for your Self Growth?
Yes! I am ready to get started!
Yes, but am open to encouragement/support.
No, but am hoping that personal coaching can help with that.
No, I am not motivated at all.
9.
How do you prefer feedback or suggestions?
An invitation and gentle suggestion for my consideration
Factual and straight to the point
I need very blunt recommendations and feedback
I need suggestions, recommendations and the encouragement to implement
I am open to suggestions but am aware it takes me awhile to incorporate
I do not do well with feedback
I do not do well with feedback and may need support around receiving & implementing feedback
Other (please specify)
10.
If you wish to schedule a Free Consultation, please follow the link on my Facebook Page or Website to book.
https://www.facebook.com/kellybakothesource
https://www.kellyyounkinsclinicalconsultant.com/contact.html
If you have already completed a Consultation, please complete the Client Demographic Form and Service Agreement that will be sent to you via link via text or email.
Thank you!
Please Send Link for Service Agreement
Please send Link for Client Demographic Form