5th September 2010 

Could therapy help you?

Assess your own needs for therapy by completing this simple questionnaire. Try not to spend too much time on each statement and be honest with yourself.

The questionnaire is in two sections. Section 1 covers what you think about yourself. Section 2 covers how you feel and behave.

The questions will help you to decide if a personal assessment of your needs would be beneficial. If you answer "yes" to more than half, or if any individual statement raises concern for you, an assessment with a Clarity therapist may help.

When you have completed the questionnaire we will make an initial assessment and respond within 5 working days.

Section 1: What you think about yourself

1 In general, people have not met my emotional needs, supported me or shown I am special to them.
YES NO


2 I sometimes worry that people I care about will leave, abandon or take advantage of me.
YESNO


3 I can be suspicious of other people's motives and have difficulty trusting them.
YESNO


4 I often feel different from others, isolated and alone.
YES NO


5 I don't let other people see the real me very often.
YES NO


6 Most other people I know are more capable and intelligent or achieve more than I do.
YES NO


7 I often struggle to get by or cope on my own.
YES NO


8 I sometimes feel as though something bad, unpleasant or difficult is about to happen.
YES NO


9 I find it difficult to maintain any distance from people I am close to.
YES NO


10 I worry about pleasing other people because they might criticise, reject or leave me.
YES NO


11 I often put the needs of others before my own or I feel bad.
YES NO


12 A lot of anger, bitterness or resentment builds up inside me that I can't really express.
YES NO


13 I must meet all my responsibilities and be the best at most of what I do.
YES NO


14 Almost nothing I do is quite good enough; I can always do better.
YES NO


15 I get upset or irritable if I can't do or get what I want.
YES NO


16 Sometimes if I get angry or frustrated; I struggle to control it.
YES NO


17 It is important for me to be liked by almost everyone I know.
YES NO


18 People that know me consider me to be a worrier.
YES NO


19 I often think about mistakes I have made and feel let down or angry with myself.
YES NO


20 How I feel about myself is based on what others think about me and what I do.
YES NO


Section 2: How you feel and behave

1 I just can't seem to get going some days.
YES NO


2 I tend to over react to situations or get upset easily.
YES NO


3 I sometimes find myself in situations that make me so anxious I feel I need to leave or get away.
YESNO


4 I find it hard to sleep, relax or wind down.
YES NO


5 I often feel alone or isolated.
YES NO


6 I am tense, anxious or nervous a lot of the time.
YES NO


7 I feel I often lack energy and enthusiasm.
YES NO


8 I feel that I can't cope when things go wrong.
YES NO


9 I am troubled by aches, pains or physical problems.
YES NO


10 My problems are hard to put to one side.
YES NO


11 I have felt hopeless or in despair at times.
YES NO


12 I feel I am to blame for my problems or difficulties.
YES NO


13 I often avoid doing things or making decisions in case I get them wrong.
YES NO


14 I often do things to avoid criticism or to gain approval from others.
YES NO


15 It is often easier to avoid my personal difficulties and responsibilities than to deal with them.
YES NO


Please complete the following basic personal information and submit the form to Clarity for assessment and feedback. All information will be held in the strictest confidence and will not be shared, transmitted or exchanged. Fields marked with an asterisk* are essential.

Your Full Name*


MaleFemale*

Date of birth*
datemonthyear


E-Mail Address*


Telephone Number including area code


Any comments?


Please submit your questionaire



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