Spiritual Distress Assessment Form
Please complete this form to help us understand your current spiritual distress and support needs. Your responses will guide appropriate care and support.
How would you rate your current level of spiritual distress?
*
None
1
2
3
4
Severe
5
1 is None, 5 is Severe
Which of the following emotional or spiritual symptoms are you currently experiencing? (Select all that apply)
*
Hopelessness
Meaninglessness
Isolation
Anger
Fear
Loss of faith
Other
What do you consider to be the main sources of your spiritual distress? (Select all that apply)
*
Loss or grief
Illness or health concerns
Family or relationship issues
Life changes or transitions
Conflict with beliefs or values
Other
How connected do you currently feel to your faith or spiritual beliefs?
*
Not at all
1
2
3
4
Very connected
5
1 is Not at all, 5 is Very connected
What is your primary faith tradition or spiritual background?
*
Please Select
Christianity
Islam
Judaism
Hinduism
Buddhism
Spiritual but not religious
None
Other
How important is spirituality or faith in your daily life?
*
Very important
Somewhat important
Not very important
Not at all important
Are you currently receiving support for your spiritual or emotional needs?
*
Yes, from a faith leader
Yes, from a counselor/therapist
Yes, from family/friends
No, not currently
What type of support would you most like to receive at this time?
*
Spiritual counseling
Emotional support
Prayer or meditation
Connection to a faith community
Other
Do you have any urgent spiritual or emotional concerns that require immediate attention?
*
Yes
No
Please briefly describe any additional concerns or needs you have related to your spiritual well-being.
Submit Assessment
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