Adult Evaluation | Mindful Psychology

Adult Wellbeing Assessment Form

This form is a first step in understanding how you are right now and providing a clear view of your emotional, mental, and physical well-being at this moment in your life.

It will help me better understand your experience and tailor the support to what you really need.

Before you answer, take a moment.

Take a breath and read each question calmly.

There are no right or wrong answers.

The only "good" answer is the one that most honestly represents what you truly feel right now.

Thank you for taking this time and for answering truthfully.

Name and surname

If you selected "Other", please explain exactly what you mean.

Are these feelings due to a recent problem or have you felt them for a long time?

If you had to choose one of these issues: which would it be? Why? What have you done before to try to resolve it? * When did this issue arise?

When does it appear? What are the associated symptoms, habits, or situations?*

To what extent is this issue currently affecting you?

Now rate from 0 to 10, quickly, without thinking too much:

How often/intensely do you identify with the following situations?

I feel hatred toward myself, low self-esteem, that I am not enough, or that I am worthless.

I cry frequently.

I experience episodes of anger.

My emotions limit me or lead me to react in ways that, upon reflection, seem disproportionate or unjustified.

I experience deep sadness.

I experience anxiety and/or panic attacks.

I feel that I lack energy.

I have thoughts of suicide.

I have difficulty sleeping.

I feel hopeless.

I feel self-love and value myself.

I am able to feel calm and relaxed

I experience moments of joy.

I am able to control my thoughts.

I have a sense of humor and enjoy laughing.

I envision a hopeful future

I treat myself with love and self-compassion when I am experiencing negative emotions.

I am able to pause and become aware of what I am thinking and feeling in the present moment.

General well-being.

I maintain a healthy diet.

I engage in regular physical exercise.

Tell me exactly what you wish to achieve. If I had a magic wand and could grant you one wish, what would it be?

What will your life be like when this issue is resolved or no longer affects you?

How will living without this issue affect your personal, professional, and social life? How will you feel?

What will you do that you don't do today or can't do? Who will you be?

How will you see life? How will you see your relationships?

What would a normal day be like without this issue?

How will you know that this topic is no longer part of your life?

What was your childhood like? Your relationship with your parents, brothers, sisters, friends, school... Feelings? Traumas?

What level of commitment do you choose to have to resolve this issue?

If you wish to add anything else, don't hesitate, now is the time to say it.

Are you currently taking any medication or receiving medical treatment for any condition? Are there any past physical or mental health concerns?

Are you in any of the following situations?

Pregnancy
Asthma
Epilepsy
Retinal detachment or glaucoma
Uncontrolled hypertension
Cardiovascular disease, including previous heart attack
Prior diagnosis by a medical professional of manic disorder, bipolar disorder, or schizophrenia
Stroke, TIA, seizures, or other neurological or brain conditions
Direct family history of aneurysms
Use of prescribed anticoagulants (such as Warfarin/Coumadin or similar)
Psychiatric hospitalization or emotional crisis in the last ten years
Severe osteoporosis, so that strenuous movement can cause injury.
Previous physical injuries that are not fully recovered and may be re-injured
Any contagious disease
Active medication use

Single option

Yes

If you selected yes, please specify and provide more information. Is there anything else you'd like to let us know?

This activity may include psychological sessions and/or hypnosis and breathwork practices, which may involve intense physical, emotional, or bodily experiences. I declare that:

I have provided truthful, complete and up-to-date information about my health status, medication and relevant background.

I have not consumed alcohol, drugs or psychedelic substances the day before the start of the session and I agree not to consume them during the session.

I did not fast excessively prior to the session.

I have been informed of the nature of the activity, the rules related to it, and the possible associated risks.

I understand that this activity does not replace medical or psychiatric care.

At no point during the intervention will any clinical diagnosis or treatment of any mental illness be carried out.

If I am under medical care for any condition, I will not make any adjustments, modifications, or discontinuations of prescribed medication without the approval of my doctor or a qualified healthcare professional.

I accept the possibility that the session may be recorded exclusively for security reasons, guaranteeing confidentiality at all times.

If I suffer from any illness, physical problem, allergy, intolerance, or if I am taking medication or have consumed substances incompatible with the activity, whether or not I have been informed, I assume full responsibility for my participation.

I expressly release Carmen Sánchez Iglesias from any liability or claim related to my physical and/or mental well-being during or after the session described and accepted through this informed consent form, assuming such participation at my own risk.

I have read and understood all the above information and I give my informed, free and voluntary consent to participate in the activity described.

I accept the terms and conditions and the Privacy Policy.