IDDM Questionnaire

Please fill this form out if you are a client participating in Integrated Daily Dialogic Mentorship (IDDM).

IDDM Questionnaire

Please take your time answering these questions. Answer all questions as thoroughly as you can.

"*" indicates required fields

Step 1 of 7

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Unique ID

Today's Date*

MM slash DD slash YYYY

Assigned Mentor*

Please select the mentor you will be working with.

Personal Information

Name*

First Last

Date of Birth*

Month

Day

Year

Sex*

Male

Female

Which of the following best describes you?*

Please select one response.

Asian or Pacific Islander

Black or African American

Hispanic or Latino

Native American or Alaskan Native

White or Caucasian

Multiracial or Biracial

A race/ethnicity not listed here.

Prefer Not to Say.

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

May we leave a message at this number?*

Yes

Please list an Emergency Contact*

First Last

Emergency Contact Phone Number*

Emergency Contact Email Address*

How did you first hear about us?*

Internet

Priest Referral

Professional Referral

Friend/Family Referral

Other

Who or where specifically?

Presenting Concerns

What type of mentorship are you seeking?*

Individual

Marital (Spouse is Present for Consultation)

What is your spouse's name?*

First Last

What is the sex of your spouse?*

Male

Female

Other

In your own words, why are you seeking our help? What sort of issues are you trying to work through?*

How stressed do you feel about your current concerns?*

Not Stressed

Mildly Stressed

Moderately Stressed

Very Stressed

Extremely Stressed

We recognize it's a big decision to start this process; it takes a lot of courage and we want to help support you through understanding where you're coming from. Why did you decide to enroll right now?*

When did you first notice your current concerns?*

(If you're not sure exactly when, that's okay, just estimate.)

Month

Day

Year

What solutions to these concerns have you already attempted?*

Have you been in therapy in the past?*

Yes

Therapist's name

Approximately how long were you engaged in therapy?

When did you discontinue therapy?

(Estimate if you're not sure exactly when)

Month

Day

Year

Have you ever been hospitalized for psychological problems?*

Yes

What was the date of your most recent hospitalization?

(Estimate if you're not sure exactly when)

Month

Day

Year

Please enter the name of the facility:

Have you ever been prescribed any psychiatric medications?*

(Check all that apply)

Yes, currently.

Yes, in the past.

No.

Please list current psychiatric medications:*

Please include approximate dosages and dates of prescription.

Please list any past psychiatric medications:*

Please include approximate dosages and dates prescribed.

Do you have any current thoughts of harming or killing someone else?*

Yes

Please describe:*

How often do you have these thoughts? Are you bothered by them? Who do you think of harming? Do you intend to follow through with these thoughts?

Do you have any current thoughts of harming or killing yourself?*

Yes

Please describe:*

How often do you have these thoughts? Are you bothered by them? Do you intend to follow through with these thoughts?

Have you ever attempted suicide?*

Yes

What was the date of the most recent attempt?*

(Estimate if you're not sure exactly when)

Month

Day

Year

Please describe the circumstances:*

Have you made multiple suicide attempts?*

Yes

Please describe additional circumstances:*

Have you experienced physical abuse or neglect?*

Yes

Have you experienced emotional abuse or neglect?*

Yes

Have you experienced sexual abuse?*

Yes

Please describe the circumstances:*

Do you currently feel safe in your home?*

Yes

Please elaborate:*

What makes your home environment feel unsafe? Are you currently in danger?

Expectations

What are your specific hopes and dreams for the future?*

5 years from now? 10 years from now?

What do you hope to gain from mentorship?*

How long do you think mentorship should last?*

One month

Three months

Six months

One year

More than a year.

As long as needed.

What about our mentorship program caught your attention?*

How do you see the role of a mentor in your life?*

What do you hope to improve in your marital relationship?*

What do you wish your spouse knew about you or better understood? How have you addressed conflict in the past and how would you like this to change?

If time and/or money wasn’t an issue, what untapped dreams and passions would you pursue?*

Faith

What is your current religious affiliation or practice?*

Buddhist

Catholic

Christian

Greek or Russian Orthodox

Hindu

Jewish

Muslim

I am not religious / I am not practicing.

Prefer Not to Say.

Other

How do you see God in your life? What role does God play?*

In your own words, describe your spirituality*

Family Dynamics

Were you adopted?

Yes

What were the circumstances of who you were raised by?

(Both parents, single parent, grandparents, etc. Were your parents married throughout your childhood? Divorced? Any other significant adults in your life?)

Describe your father's personality and his attitude towards you (growing up and now).*

Describe your mother's personality and her attitude towards you (growing up and now).*

What did your parents teach you about marriage with their example? What did they model for you as far as communication, intimacy, sexuality, conflict resolution, gender roles, etc.?

How were you disciplined as a child?*

What significant life events occurred in your family of origin?*

What are your family of origin's strengths?*

What are your family of origin's weaknesses?*

Does anyone in your family suffer from any of the following?

Check all that apply.

Alcohol Abuse

Drug Abuse

Anxiety

Depression

Other Mental Illness

Has anyone in your family or close to you attempted or committed suicide?*

Yes

Describe the circumstances (who and when?)

Have you or any relatives had serious criminal problems?*

Yes

Describe the circumstances (who and when?)

Have you or anyone in your family had an abortion?*

Yes

Describe the circumstances (who and when?)

Please list the members of your family.*

(Add a row for each member of your family of origin and immediate family by clicking the plus symbol)

Name

Relationship

Age

Quality of Relationship

Deceased (Y/N)

If yes, your age when relative passed

Including yourself, How many people currently live in your household?*

Social Dynamics

Who are the most important people in your life?*

Do you make friends easily?*

Yes

Do you keep them?*

Yes

Do you have one or more friends you feel comfortable sharing your most private thoughts and feelings?*

Yes

Do you generally express your feelings, opinions, and wishes to others?*

Yes

How would you describe your political view?*

Very Liberal

Slightly Liberal

Moderate

Slightly Conservative

Very Conservative

Prefer not to say

To what degree do you feel generally comfortable and relaxed in social situations?*

Very Relaxed

Relatively Comfortable

Neutral

Relatively Uncomfortable

Very Anxious

Describe those people or situations in which you have trouble asserting yourself.*

Have you had any legal involvement?*

Have you been arrested, faced any criminal charges, or been involved in the court system.

Yes

Prefer Not to Say

Please Explain the Context:*

Do you use drugs or alcohol?*

Yes

Prefer Not to Say

Please Describe Your Drug or Alcohol Use*

This could include how many times you use substances in a week or month, how much and what type on a given occasion. Have you or anyone close to you ever felt like your alcohol or drug use was excessive? Has it impaired your life in any way? Are there particular situations where you are more apt to use substances?

What is your Sexual Orientation?*

Heterosexual

Homosexual

Bisexual

Pansexual

Asexual

Other

Describe your dating history.*

Describe your first romantic encounter (age, circumstances).*

Describe your first sexual encounter (age, circumstances).*

Describe your current sexual functioning.*

Frequency of engagement with sexual partners? Frequency of pornography use and/or masturbation?

Have you ever been (check all that apply):*

Married

Separated

Divorced

Widowed

None of these apply to me

Please Describe the Circumstances*

Relationship Status*

Are you currently seeking a relationship?*

Yes

Do you feel called to a specific vocation?*

Yes

What do you feel called to?*

How do you feel about being single?*

How long have you been dating your significant other?*

How far along are you in discerning marriage with the person you are dating?*

Describe your relationship*

Strengths, Areas for Growth

Describe the sexual history of your relationship.*

Describe your relationship with your significant other's friends and family.*

How do your friends and family feel about your significant other?*

How long did you date before you were engaged?*

How long have you been engaged?*

Do you have a wedding date set?*

Yes

What is your wedding date?*

MM slash DD slash YYYY

How long were you engaged before you got married?*

How long have you been married?*

How often do you engage in sexual relations with your spouse?*

How long did you discern before entering a celibate vocation?*

Are you in final/perpetual vows?*

Yes

How long were you in your celibate vocation before making final vows?*

How long have you been in final vows?*

How long until you are eligible for final vows?*

Describe your intimacy with God.*

What are the strongest aspects of your celibacy and what areas are in need of strengthening?*

For how long do you experience contemplative prayer each day or week?*

How do your friends and family feel about your celibacy?*

Do you have any spiritual children?*

Yes

Do you have any biological children?*

Yes

Do you have any adopted children?*

Yes

Describe your Relationship with these Children

Do any of your children present special problems?*

Yes

Please describe.*

Occupational Dynamics

What is the highest degree or level of school you have completed?*

If currently enrolled, highest degree received.

Describe your experience during grade school*

(i.e. friendships, sports, clubs/organizations, honors, grades, etc.).

Describe your experience during junior high school*

(i.e. friendships, sports, clubs/organizations, honors, grades, etc.).

Describe your experience during high school*

(i.e. friendships, sports, clubs/organizations, honors, grades, etc.).

Describe your experience during college*

(i.e. friendships, sports, clubs/organizations, honors, grades, etc.).

Describe your experience during graduate school*

(i.e. area of study, friendships, sports, clubs/organizations, honors, grades, etc.).

Any behavioral or academic difficulties?*

Current Employment Status*

Full-Time Employment

Part-Time Employment

Unemployed

Self-Employed / Independent Contractor

Home-Maker

Student

Retired

Prefer Not to Say

What is your current annual household income:*

Less than $20,000

$20,000-$35,000

$35,000-$50,000

$50,000-$65,000

$65,000-$80,000

$80,000-$100,000

$100,000-$150,000

$150,000-$200,000

$200,000-$350,000

$350,000-$500,000

$500,00+

Prefer Not to Say

How would you describe your relationship with money?*

Please list your employment history, beginning with your most recent position.*

Add new rows for additional positions with the plus symbol at the end of the row.

Place

Position

Dates

Reason For Leaving

Does your present work satisfy you?*

Yes

Please explain why not.*

Do you have any problems with people at work?*

Yes

Please explain.*

What are your past employment ambitions?*

What are your current employment ambitions?*

Medical History

Please describe any complications during your birth that you know of.*

Please describe any surgeries you've had, with approximate dates.*

Please describe any injuries or accidents you've had, including head injuries or times you've lost consciousness, with approximate dates.*

Please describe any chronic illnesses you suffer from.*

Do any of the following apply to you?

Check all that apply.

Thyroid Disease

Asthma

Infectious Disease

Diabetes

Glaucoma

Prostate Problems

Kidney Disease

Cancer

Epilepsy

Neurological Disease

Gastrointestinal Disease

Migraines

Do any of the following apply to anyone else in your family?

Thyroid Disease

Asthma

Infectious Disease

Diabetes

Glaucoma

Prostate Problems

Kidney Disease

Cancer

Epilepsy

Neurological Disease

Gastrointestinal Disease

Migraines

Self Perceptions

List your three main fears.*

2.*

3.*

What do you consider to be your most irrational thought or idea?*

Please list your strengths.*

Add a new row for each strength with the plus symbol at the end of the row.

Please list your weaknesses.*

Add a new row for each weakness with the plus symbol at the end of the row.

What’s your inner voice say about you on your best day? On your worst day?*

Thank you for filling out this questionnaire, it will help us get off to the best start. One last question: Was there anything surprising that came up for you here in filling out this questionnaire?*