Confidential Questionnaire
Directions: Please answer the following questions from
your own perspective. If needed, use
the back of this form to complete your answers.
Today’s Date _____________________
Name __________________________________________Date of Birth
__________________
1.
How were you referred to Jonathan Bundt?
2.
What would you name the problem, issue or concern that
brought you to see Jonathan Bundt?
3.
Who or what is the person/issue you are most concerned about
and why?
Listed below are possible problems you or your family may be
struggling with. Please circle and rate
each issue according to your degree of concern and state why:
1. Suicide Potential (Low) 1 2 3 4 5 6 7 (High)
Why?
2. Depression (Low) 1 2 3 4 5 6 7 (High)
Why?
3. Anxiety/Worry (Low) 1 2 3 4 5 6 7 (High)
Why?
4. Alcohol/Drug Abuse (Low) 1 2 3 4 5 6 7 (High)
Why?
5.
Family/Relationship Conflict
Why? (Low) 1 2 3 4 5 6 7 (High)
6. Legal Problems (Low) 1 2 3 4 5 6 7 (High)
Why?
7.
Verbal Abuse/Behavior
Why? (Low) 1 2 3 4 5 6 7 (High)
8.
Sexual Abuse/Behavior
Why? (Low) 1 2 3 4 5 6 7 (High)
9.
Physical Abuse/Behavior
Why? (Low) 1 2 3 4 5 6 7 (High)
10.
Job/School Conflicts
Why? (Low) 1 2 3 4 5 6 7 (High)
11.
Other Problem/Behavior
Why? (Low) 1 2 3 4 5 6 7 (High)
Why do you think there are these problems for you or your
family?
What is the main goal or need you have for today’s session?
What are your ideas on how that goal can be accomplished?
Please list any questions or particular concerns you may
have for Jonathan.
Please mention any other comments that you would like to add, or things you believe is important for Jonathan to know.