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The Questions
ALTA Intake Questionnaire
Step 1 of 7
14%
Your Personal Information
Name
*
First
Last
Email
*
Phone
*
City
*
State/Province/Region
*
Country
*
Date of Birth
*
Level of Education
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High School
Associate Degree
Bachelor's Degree
Graduate of Professional Degree
Some College
Other
- Select -
Gender
Male
Female
- Select -
Marital Status
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Single
Married
Divorced/Seperated
Widowed
- Select -
What challenges or issues might you like to resolve in your personal or business life?
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Answering Instructions:
It is NOT required that you answer ALL of the following Education Questions. You have four answering options: 1. Leave it blank and unanswered, 2. Mark it as Excelled, 3. Mark it as Enjoyed, or 4. Mark it as Struggled.
Educational Subjects of Interest: English
Please mark the following list of High School or College English classes as: Struggled, Enjoyed, or Excelled. On those that don't apply simply skip them and leave blank.
Literature
Excelled
Enjoyed
Struggled
Poetry
Excelled
Enjoyed
Struggled
Journalism
Excelled
Enjoyed
Struggled
Creative Writing
Excelled
Enjoyed
Struggled
Educational Subjects of Interest: The Sciences
Please mark the following list of High School or College Science classes as: Struggled, Enjoyed, or Excelled. On those that don't apply simply skip them and leave blank.
Biology
Excelled
Enjoyed
Struggled
Chemistry
Excelled
Enjoyed
Struggled
Physics
Excelled
Enjoyed
Struggled
Geology
Excelled
Enjoyed
Struggled
Technology
Excelled
Enjoyed
Struggled
Educational Subjects of Interest: Business
Please mark the following list of High School or College Business classes as: Struggled, Enjoyed, or Excelled. On those that don't apply simply skip them and leave blank.
Business Law
Excelled
Enjoyed
Struggled
Economics
Excelled
Enjoyed
Struggled
Educational Subjects of Interest: Mathematics
Please mark the following list of High School or College Math classes as: Struggled, Enjoyed, or Excelled. On those that don't apply simply leave blank.
General Math
Excelled
Enjoyed
Struggled
Business Math
Excelled
Enjoyed
Struggled
Algebra
Excelled
Enjoyed
Struggled
Geometry
Excelled
Enjoyed
Struggled
Calculus/Trigonometry
Excelled
Enjoyed
Struggled
Educational Subjects of Interest: The Arts
Please mark the following list of High School or College Artistic classes as: Struggled, Enjoyed, or Excelled. On those that don't apply simply leave blank.
Drawing/Sketching
Excelled
Enjoyed
Struggled
Sculpting
Excelled
Enjoyed
Struggled
Painting
Excelled
Enjoyed
Struggled
Photography
Excelled
Enjoyed
Struggled
Design: Graphic/Web
Excelled
Enjoyed
Struggled
Music
Excelled
Enjoyed
Struggled
Dance
Excelled
Enjoyed
Struggled
Drama
Excelled
Enjoyed
Struggled
Educational Subjects of Interest: Social Studies
Please mark the following list of High School or College Social Study classes as: Struggled, Enjoyed, or Excelled. On those that don't apply simply leave blank.
Government/Politics
Excelled
Enjoyed
Struggled
Geography
Excelled
Enjoyed
Struggled
History
Excelled
Enjoyed
Struggled
Psycology
Excelled
Enjoyed
Struggled
Sociology
Excelled
Enjoyed
Struggled
Anthropology
Excelled
Enjoyed
Struggled
Foriegn Language
Excelled
Enjoyed
Struggled
Educational Subjects of Interest: The Trades
Please mark the following list of High School or College Vocational classes as: Struggled, Enjoyed, or Excelled. On those that don't apply simply leave blank.
Automotive
Excelled
Enjoyed
Struggled
Carpentry/Woodworking
Excelled
Enjoyed
Struggled
Metal Working
Excelled
Enjoyed
Struggled
Electrical
Excelled
Enjoyed
Struggled
Computer Repair
Excelled
Enjoyed
Struggled
Drafting/Architecture
Excelled
Enjoyed
Struggled
Educational Subjects of Interest: Physical Education / Sports
Please mark the following list of High School or College P.E. classes as: Struggled, Enjoyed, or Excelled. On those that don't apply simply leave blank.
Gymnastics
Excelled
Enjoyed
Struggled
Martial Arts
Excelled
Enjoyed
Struggled
Field Sports
Excelled
Enjoyed
Struggled
Swimming
Excelled
Enjoyed
Struggled
Occupation / Career Questions
Describe the activities of your current occupation. (If currently unemployed please state your prior occupation.)
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Are your EXPECTATIONS being met by this occupation? Why or why not?
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What do you feel is IMPORTANT about your occupation?
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What gives your occupation MEANING and why?
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What do you do to ESCAPE mentally from your daily occupational activities?
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While interacting professionally with your customers you prefer to either: A) Establish quality relationships somewhat like a counselor with a client or B) Connect with others usefully in the moment and no deeper.
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A) Establish relationships
B) Connect
- Select -
Three Events of Well-being
Name three specific moments in your adult life that gave you a feeling of either happiness, satisfaction, well being or contentment.
Happy Event 1
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Describe why it was satisfying for you.
*
Happy Event 2
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Describe why it was so fulfilling for you.
*
Happy Event 3
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Describe why it made you happy.
*
8. Three Frustrating Events
Name three specific events in your adult life that made you angry, frustrated, extremely irritated or otherwise greatly dissatisfied.
Frustrating Event 1
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Why did you find this event so disatisfying?
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Frustrating Event 2
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Why did you find this event so frustrating?
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Frustrating Event 3
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Why did this event anger you?
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What make, model and year is the car that you drive? If you own two or more state your favorite?
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Explain why you bought that particular kind of automobile?
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When you make purchases for YOURSELF ONLY you tend to be:
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Very frugal
Frugal
Moderate
Somewhat indulgent
Indulgent
- Select -
Describe what you do to relax?
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Describe a hobby of yours.
*
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