Spiritual Counseling Form - OSW Spiritual Wellness

DEMOGRAPHICS FIRST

This is where you will complete all of the necessary information I may need If I need to call anyone "in case of an emergency" situation.

Unfortunately I have been left in this situation in the past with nothing to "hand off" to staff. It is not a good feeling for anybody.

I am not a licensed healthcare provider and I do not pretend to be, but I can be a good listener and help you sort through things and provide support via Reiki.

Full Name

Address

Phone

EMERGENCY CONTACT - NAME

EMERGNECY CONTACT PHONE #

HEALTH HISTORY

A brief health history questionnaire.

FAMILY HISTORY

	N/A ADOPTED	FATHER	MOTHER	SISTER	BROTHER	FATHER'S DAD	FATHER'S MOM	MOTHER'S DAD	MOTHER'S MOM
DIABETES
HEART DISEASE
BRAIN CANCER
BREAST CANCER
COLON CANCER
LUNG CANCER
MUSCULAR SCLEROSIS
ANXIETY / DEPRESSION
ADDICTION DISORDER
OTHER

OTHER

REVIEW OF SYSTEMS

Here we will discuss how you have been feeling

Please check what applies

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree	N/A
I feel fine lately.
I have many friends.
I go out drinking every weekend.
I have more drinks than I should when I go out.
I talk to my friends daily.
I do not think about self harm.
If I think about self harm, its purely a thought and I do not act.
I have a plan to self harm.

Text

CONSENT

Here is where you will consent to speak with me. Everything will be confidential between us. Having worked in the medical field for over 20 years, I understand patient privacy; however, I also understand the need for patient safety. If I feel at any time you are in danger, I will call proper authorities and agencies. I am not a healthcare provider and I am not licensed to treat patients. I am making this clear now and throughout our discussions as I am purely a person to chat with and bounce ideas off of.

Please type your full name & date of birth.