Shari Jonas LifeFX Assessment Form

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Thank you for your interest in working with me. I'm excited to delve into the issues and concerns that you are currently having. Before we get started, it is important for me to understand more about your goals so that I can properly assess how I can be of service to you. The more insight you can share with me here, the better I can ascertain your needs. As with all professional client/counsellor relationships, everything that you disclose about yourself, both on this form and during our discussions, will be strictly confidential.

Email *

Your Full Name

Your Email Address (Please indicate if this is a confidential email or do other family members have access to it.)

Your Birth Date (include month and year only)

Your Marital Status (single, engaged, married, common law, separated, divorced)

If Separated or Divorced, please indicate for how long.

Your Parental Status: Do you have children and/or step-children, and if so please indicate how many, their sex/gender and ages?

Your Living Status: Do you live with a partner, children, step-children and/or other members of your extended family? Please explain your current living situation in as much detail as possible.

Primary Reason for Counselling

Any additional issues that you have and would like to discuss, outside of the primary reason?

Have you ever had counseling? If so, please share with me if those issues were resolved, keep recurring, or are these new concerns.

Are you currently taking any prescriptions related to psychological disorders? (ie. anti-depressants, anti-anxiety, etc.)

Yes

Other:

Your Expectations: What is your ideal goal that would like to achieve from speaking with me? Feel free to share any outcomes that you are hoping to experience. The more specific you can be, the better.

What are the best days and times of the week, where we can speak on a regular basis?

Which country and time zone are you in?

How did you hear about me?

Are there any other comments, questions or concerns that you have?

Regarding payment, I work on a sliding scale based on number of sessions. I will send you my current rate fees upon completion of this form, with discounted fees for pre-booking multiple sessions.

I understand

Other:

By submitting this form, you are fully aware that the success of any therapy/counselling and coaching has to do with your willingness to be fully transparent, even when it is difficult, and that by you doing the "work" is the only way for you to make any progress and ultimately to find resolution with your issues.

I agree

I disagree

RELEASE: I acknowledge that Shari Jonas is not a medical doctor and cannot prescribe any type of medication to me. She is trained as a Family Life Educator and can provide me with a multitude of solutions that pertain to non-medical issues. Should I require prescription drugs for depression, anxiety or neurodivergent disorders, that I will seek medical advice. *

I agree

I disagree

Required

Send me a copy of my responses.

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