Counseling & Mentoring Questionnaire
Nalanda Institute for Contemplative Science
nalandainstitute.org
First Name *
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Last Name *
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Address
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Phone
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Email *
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Are you looking for counseling or coaching/mentoring? *
COUNSELING is for those who want help using contemplative insights and methods to work through challenges in their personal life; MENTORING or COACHING is for those who want guidance on how to weave contemplative science and practice into their professional life.
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Insurance provider (if you are looking to use insurance).
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Do you need a sliding scale for session fees? If so, what is your fee range for services? *
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What brings you to counseling/mentoring at this time? Is there something specific—a particular challenge or event? *
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What are your goals for counseling/mentoring? Short-term/long-term
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Have you had any experience with meditation, yoga, or other contemplative practice?
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Do you have a regular contemplative practice--if so, please describe it; if not, do you want to develop one?
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Whether you’re seeking counseling or mentoring, have you had a counselor/mentor before? For how long? Was it a good, neutral or bad experience? *
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Are you physically healthy or have you had health conditions to manage recently or in the past? *
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Are you taking any medications or supplements? If so, do you have a prescribing MD? *
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Do you have/want to develop healthy lifestyle habits—exercise, diet, sleep, work/life balance?
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Do you smoke, drink alcohol, or use recreational drugs, and if so how much, how often? *
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If you would like, please describe your family of origin—your place in the birth order, what was the family’s emotional style?
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Do you or have you ever had thoughts or urges to harm yourself? Others? *
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Have you ever actually tried to harm yourself or take your life? *
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Have you ever needed to go to an emergency room or hospital for psychiatric care or addiction treatment? *
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Is there a history of mental illness, substance abuse, domestic violence, or intergenerational trauma in your family?
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Please check any of the following you have experienced in the past six months: *
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What else would you like us to know?
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