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Assessment Form

All entries on this form are confidential and will help our Counsellors have a background knowledge of your person. Please complete with the accurate information. Thank you!

Firstname *

Lastname *

Email Address *

Phone Number *

Gender *

Female
Male
Others

I usually feel sad and unhappy about my life and experiences *

Rarely
Sometimes
Often
Always

I am usually very worried about how my life will turn out *

Rarely
Sometimes
Often
Always

I believe I can't make it *

Rarely
Sometimes
Often
Always

I believe in my ability to build a sense of personal strength as I go through life *

Rarely
Sometimes
Often
Always

I am usually very fast in recovering from challenges and difficulty *

Rarely
Sometimes
Often
Always

I blame myself for what has happened to me *

Rarely
Sometimes
Often
Always

I get tensed and agitated when I have to do things *

Rarely
Sometimes
Often
Always

I often relive or re-experience traumatic events when I'm alone *

Rarely
Sometimes
Often
Always

I have difficulty achieving my goals no matter how much I try *

Rarely
Sometimes
Often
Always

Making decisions about my life is often difficult for me *

Rarely
Sometimes
Often
Always

Do you have Children? *

How Many?

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Assessment Form

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