Spiritual Care Screening Tool
Patient Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Today's Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have any spiritual need where we can offer support?
*
Yes
No
How urgent is that need?
*
Extremely urgent. I am desperate!!
I need help urgently.
I need help, but it is not urgent.
I am ok.
How would you describe your faith today?
*
Active
Beginning Stage
Unsure/Questioning
Open/Curious
Not interested
My spiritual practices at this moment are (please click all that apply):
*
None
Prayer
Devotion
Attending church or faith community
Sacred scripture reading/studying
Other
How close/far do you feel from God at this time in your life?
*
Very Close
Somewhat Close
Not Sure
Somewhat Far
Very Far
Do you have someone who cares for you and loves you?
*
Yes
No
Please ask us about our daily morning devortions via Zoom. You are always welcome to join us!
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