Form

1. What is your gender identity ?

Male

Female

Other

Prefer not to say

2. How old are you ?

12-17

18-23

24-30

31-40

41-55

3. Have you ever been in therapy before ?

Yes

4. What led you to consider therapy today ?

I feel anxious or overwhelmed

I've been feeling depressed

I am grieving

I can't find purpose and meaning in life

I have experienced trauma

I am concerned about my body

I struggle with building or maintaining relationship

5. Do you consider yourself religious ?

Yes

6. Have you been feeling bad about yourself - or that you are a failure, over the last 2 weeks ?

Not at all

Several days

More than half the days

Nearly every day

7. How difficult had these problems made it for you to do your work, take care of things at home or get along with people ?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

8. Have you been facing trouble concentrating on things, such as reading the newspaper or watching television, over the last 2 weeks ??

Not at all

Several days

More than half the days

Nearly every day

9. Have you been feeling tired or having low energy all the time, over the last 2 weeks ??

Not at all

Several days

More than half the days

Nearly every day

10. Have you been feeling down, depressed or hopeless, over the last 2 weeks ??

Not at all

Several days

More than half the days

Nearly every day

Your stress level is 22.

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