Free web therapy assessment for online therapy sessions

Name

Marital status

Number of children

Choose which is applicable:

I’m in a relationship which is hurtful and unhealthy

I feel trapped in a relationship which is unsatisfying and going no where

My communication with my partner is problematic and we can’t agree or solve any of our problems

I am in an abusive relationship where I suffer

I am in a healthy relationship where we argue yet in a healthy and productive way

None of the above.

In the last two years for two weeks or more:

I felt helpless, hopeless, and worthless.

I lost or gained substantial weight.

I had difficulty in working, functioning in general.

I couldn’t sleep or slept too many hours and couldn’t get out of bed.

I had no appetite or ate all the time

I am slow in functioning and or can’t concentrate easily.

I find no pleasure in anything any more.

None of the above.

In the last two years for two weeks or more:

I have felt anxious or anxiety and cant seem to stop feeling like I’m incapable of completing a task.

When I feel anxious I cant seem to reassure myself.

When I feel anxious I am easily irritated, angered, and distracted.

I feel overwhelmed and feel fearful that I will suffer anxiety and panic over bad situations that may happen.

Dooming thoughts and negative thoughts constantly haunt my thoughts.

I don’t go places or avoid situations due to these dooming thoughts.

None of the above.

In the last two years for two weeks or more:

I fear animals, objects or situations and stay in a secure environment.

I fear social situations and avoid any.

I have a great fear or large crowds or crowded stores and situations where a lot of people gather (i.e. concerts, malls).

I have a fear of bad situations.

I have persistent fixation of bad thoughts.

I have a tendency of having to do such actions repetitively (rituals).

None of the above.

In the last two years for two weeks or more:

I have a need to control everything in my life and all my loved ones.

I have a need to be prefect at everything I do.

I feel incapable of taking care of myself.

I have a hard time saying NO to people around me.

I never disagree with anyone because I may be disliked.

I feel as though I cant do anything alone.

I always need to be in a relationship.

I feel constant pain which cant be explained by medical exams.

None of the above.

In the last two years for two weeks or more:

I have an addiction: alcohol. drugs, and or gambling.

I have a problem eating or digesting the required food intake.

I have a problem with my body image.

I can’t seem to stop eating when I’m full.

I feel guilty after eating regardless of how much I ate.

I eat all the time.

I overeat when I’m sad or upset or mad.

None of the above.

In the last two years for two weeks or more:

I don’t really like myself.

I worry that the people I care about will abandon me.

I feel empty almost all the time.

I describe people as being great or bad.

My relationship are unstable.

My behavior is irresponsible and dangerous to myself and/or others.

None of the above.

In the last two years for two weeks or more:

I don’t seem to finish what I start.

I cant seem to concentrate on anything for a long period of time.

I am very disorganized.

I seem to loss my things all the time.

I seem to collect things and not throw things away.

I seem to not be able to sit still or listen for a long period of time.

None of the above.

What are your realistic goals? What do you REALLY want to achieve?

Have you been life coached in the past

If yes please describe your life coaching experience

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Your Country

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Languages you speak

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