ASPIRE Clinic
Holistic Initial Consultation Assessment (HICA)
The ASPIRE Clinic is a unique resource that offers a variety of holistic services that can help you enhance your feelings of well-being and satisfaction. Please answer the following questions, as they will help your service provider determine what ASPIRE services could be of benefit to you. Based on their recommendations or your own interests, you are welcome to pursue anyservice area of ASPIRE that aligns with your personal goals.
The following questions are about your personal well-being and relationship satisfaction.
Are your family relationships or situations currently causing you stress?
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Not at all Sometimes Often
Is your romantic relationship (marriage, partner, etc.) currently causing you stress?
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Not at all Sometimes Often
Do you feel emotional or psychological stress related to your current struggles?
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Not at all Sometimes Often
Do you struggle with a sense of purpose and value in your life?
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Not at all Sometimes Often
Do you experience low, depressed mood or anxiety?
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Not at all Sometimes Often
How satisfied are you with your current personal relationships?
1 2 3 4 5
Not at all satisfied Somewhat satisfiedCompletely satisfied
The following questions are about your current financial situation.
Are you experiencing stress related to your finances?
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Not at all Sometimes Often
Do you feel confident that you are saving enough money for your future goals?
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Not at all Sometimes Often
Do you experience relational conflict related to finances?
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Not at all Sometimes Often
Are you interested in learning more about personal financial planning?
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Not at all Sometimes Often
How satisfied are you with your current financial situation?
123 45
Not at all satisfied Somewhat satisfiedCompletely satisfied
The following questions are about your personal health and nutrition.
Do you feel you need more information on buying healthy groceries and meal planning on a budget?
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Not at all Sometimes Often
Are you concerned about your nutritional or health status?
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Not at all Sometimes Often
Are you concerned about the nutritional or health status of other members of your household?
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Not at all Sometimes Often
How motivated are you to change your eating habits?
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Not motivatedSomewhat motivatedVery motivated
Do you feel you need to lose or gain weight?
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Not at all Sometimes Often
How satisfied are you with your current nutrition and health?
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Not at all satisfied Somewhat satisfiedCompletely satisfied
The following questions are about your current legal concerns.
How important is it for you to talk with a lawyer about a present or future court case?
1 2 345 No current case Curious Possible Important Urgent
How much do you need to talk with a lawyer about future plans, such as a contract, a will, health decisions, a marriage, a business, or personal finances (including debt)?
1 2 345
Not at allCurious Possible Important Urgent
How much impact do your legal concerns have on your peace of mind?
1 2 345
None Some Severe
For how long have your legal concerns affected you?
No current concern Less than 3 mos. 3 – 12 mos. 1 – 3 yrs. 3 yrs.+
How satisfied are you with your current legal situation?
1 2 3 4 5
Not at all satisfied Somewhat satisfiedCompletely satisfied
The following questions are about your home environment.
Do you feel that the interior environment of your home is an outward expression of you and/or your family?
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Not at all Sometimes Often
Do you feel the space and layout of your home functions and supports the interactions, activities, and health of you and your family?
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Not at all Sometimes Often
Do you feel the design of your home is safe and comfortable for you and your family?
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Not at all Sometimes Often
Are you concerned with you or family members safely getting around your home due to illness, disability, or age?
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Not at all Sometimes Often
Are you motivated to make changes to the design, layout, or organization of your home in order to achieve a healthy and functional interior environment?
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Not at all Somewhat Motivated Very Motivated
How satisfied are you with your current home environment?
1 2 3 4 5
Not at all satisfied Somewhat satisfiedCompletely satisfied
We thank you for completing this information! Please turn all paperwork in to the
ASPIRE intern in the front office when completed.
For Office Use:
Case #: ______
Ind ID#______