Spiritual Assessment Form

Miriam's Hope Assessment Questions

For questions that do not apply, simply leave un-answered.

Full Name

Date

Phone

Email

Family

How is your family?

What are the greatest issues in your family?

How many times a month do you and a friend go out alone?

How much of your conversations have been positive and encouraging?

How much time have you read the word and prayed for your family?

How much time have you spent doing enjoyable things with your children?

What percentage of your time do you spend correcting your child/ren?

Do your children look positive or negative at how you live your life?

How satisfied are you with your style of parenting?

Select all that apply to you.

Hopelessness/helplessness/worthlessness Withdrawn from people Anger/frustration/moody/irritable/weepy Hard time focusing/poor memory/indecisive Desire to escape Change in eating habits Fatigue/lack of energy No vision/no desire to achieve/no desire for pleasure Sleeplessness Feelings of suicide

How d you feel about life in general?

Spiritual Life

How often do you spend time in God's Word? Just you and the Bible?

How often to do take time to worship God?

What are your greatest struggles with God right now?

Is your passion for knowing and trusting God increasing or decreasing?

What is your greatest temptation category?

How often do you take a day to rest (do nothing) and focus on God?

Can you name three Christian friends who you would call in moments of trial? (Also indicate the last time you spoke to them.)

1.

2.

3.

Physical Life

How is your healthy nutrition intake?

How much have you been exercising? (Increasing heart rate for a minimum of 15 minutes)

What are your physical ailments? (Include things like anxiety and depression)

How refreshed and energized do you feel?

Last time you had a physical?

Soul Life (Mind)

How refreshed is your mental fuel tank?

What hurts/pains are you carrying in your soul?

How much stress do you feel right now?

What are your top three things you are concerned about in life?

1.

2.

3.

Is your mind thinking more positive or negative about life?

What books are you reading to feed into your soul?

How many hours of sleep are you getting each night?