Creative Interfaces

This questionnaire is used to provide your potential Coach, Counselor, or Spiritual Director with a little information about you.

Please answer each question and then submit the form. Your information will be held in confidence and will never be shared with anyone except the Coach, Counselor, or Spiritual Director you choose.

First Name

Last Name

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (optional)

(###)

###

####

1. What you're looking for *

Which of the following best describes what you're looking for?

Spiritual Direction (spiritual calling and future)

Personal Counseling (inner change or healing)

Creativity Coaching (awakening your unique creative "voice")

2. If he or she is available, whom would you like to see? *

Dave Robinson, MDiv, DpEL, DMin (Pastoral Counseling, Creativity Coaching)

Matt Krick, MA, CSD (Spiritual Direction)

Jenny Alphin, TRS, CEGE (Equine Guided Education and Coaching)

Marybeth Adkins, CSD (Spiritual Direction)

I'm not sure

3. Are you currently seeing a therapist or counselor? (optional)

Yes

No

4. Have you ever been diagnosed with a mental illness? *

Knowing this information ahead of time can be very helpful as we consider your needs as well as our qualifications.

None

Mild Depression

Severe Depression

Bipolar Disorder / Manic Depression

Schizophrenia

Other

6. Who will be present? *

Generally, our sessions are done in a one-on-one context. However, sometimes it's wise to include someone else (such as one's spouse) from time to time.

This will be just me

This may involve my spouse

This may involve someone else

I'm not sure