Free Consultation Questionnaire

This questionnaire will simplify your path to overcome depression, anxieties, trauma, angers and addictions and get you on the fast track to recovery.

Complete and send to me

Name

Your Phone Number (required, to avoid junk mail problems)

To begin there are three questions for you to answer in your own words.

Briefly describe your problems and for how long you have had them. And score their seriousness (1 to 5)

When we have finished how will you know I have helped you? What will have changed?

State the three qualities you have that you are most proud of and believe are reliable and true for you.

And now answer these 16 questions. You can do that by clicking the score for each question in the appropriate space:
0 is NOT AT ALL
1 is OCCASIONALLY
2 is SOMETIMES
3 is OFTEN
4 is ALL THE TIME

When giving your answer, focus on how the last week has been.

Depression

I am mentally and emotionally exhausted?

0 1 2 3 4

I can barely drag myself out of bed in the morning?

0 1 2 3 4

I feel trapped in my head – unable to escape thoughts, projections and self obsessions, even though I know they are doing me no good?

0 1 2 3 4

I have difficulty getting to sleep or staying asleep?

0 1 2 3 4

Anxieties

I am tense, anxious or nervous?

0 1 2 3 4

I am watching and aware how my body is feeling and reacting?

0 1 2 3 4

My head is full of negative “what if” scenarios?

0 1 2 3 4

There are situations or phobias that terrify me when I am exposed to them?

0 1 2 3 4

Trauma, Patterns and Addictions

I have unwanted images or memories that are distressing me?

0 1 2 3 4

I am living with a past event or experience that extended over a long period of time?

0 1 2 3 4

I have self sabotaging patterns that appear again and again?

0 1 2 3 4

I have addictions – either food, alcohol, substances, behaviour or obsessive thoughts?

0 1 2 3 4

Your Life Now

I feel unsafe and insecure in major aspects of my life?

0 1 2 3 4

I believe my life and the work I do (paid or unpaid) has little meaning and makes no worthwhile contribution?

0 1 2 3 4

I have no one to turn to for support when needed?

0 1 2 3 4

I am not looking after myself – around nutrition, exercise and leisure/relaxation?

0 1 2 3 4