Gestalt Therapy Assessment
Please complete this assessment to help us understand your current experiences and support your therapeutic journey.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Current Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please rate the following aspects of your present experience:
*
Rows
Not at all
A little
Somewhat
Very much
Awareness of body sensations
1
2
3
4
Awareness of emotions
5
6
7
8
Clarity of thoughts
9
10
11
12
Sense of connection to others
13
14
15
16
How would you describe your current mood?
*
Calm
Anxious
Sad
Irritable
Other
Please rate your level of satisfaction in the following areas of your life:
*
Rows
Very dissatisfied
Dissatisfied
Neutral
Satisfied
Very satisfied
Work/School
17
18
19
20
21
Relationships
22
23
24
25
26
Physical Health
27
28
29
30
31
Emotional Well-being
32
33
34
35
36
How often do you feel present and aware in daily life?
*
Never
1
2
3
4
5
6
7
8
9
Always
10
1 is Never, 10 is Always
Which of the following best describes your current coping strategies when facing stress?
Talking to friends or family
Physical activity/exercise
Meditation or mindfulness
Avoidance/Withdrawal
Other
What would you like to focus on during your therapy sessions?
Signature (please sign to confirm your answers and consent)
*
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