Intake Questionnaire » Mind-Sculpt

Individual Client Questionnaire

Name *

Phone *

Email Address *

What brings you to Mind-Sculpt? *

Screening Questions

Have you been diagnosed with any serious mental health issues? *

Approximately how much time and money have you invested so far in looking for solutions? What methods? *

Commitment to Progress

The commitment to working with Mind-Sculpt is very important. Your provider will explore every available option to help you and your particular challenges. With that, please answer the following questions:

Time and Place *Can you dedicate up to 6 hours per week to your growth?Will you be in Southern California (LA, OC, North SD) for the next three months?

How much of a priority is your mental wellness and improving yourself at a brain-body level on a scale of 1-5, 5 being top priority *

Financial Situation: What is your financial situation like currently? Are you fairly comfortable and capable of making the investment in yourself? *

Your Goals

What are your three greatest strengths? Three greatest weaknesses? *

How much trauma do you feel you have sustained throughout your life? *(1) Not much at all (2) A few instances (3) Several instances; ongoing (4) Quite a bit (5) My life has been a nightmare I'd like to wake up from

Are you "stuck" on a particular challenge? What are the circumstances in which that challenge keeps presenting itself to you? *

What does optimal mental wellness mean for you? *