Counselling Self Assessment Questionnaire

This questionnaire is designed to help you decide if counselling would be beneficial to you at this time.

Generally, if you answer   YES   5-6 times, or    SOMETIMES    8 or more times, you may benefit from counselling at this time.

After filling in this questionnaire, you can then decide whether to submit it for one of our counsellors to call you back and discuss your responses.  Alternatively you are welcome to contact us directly on :

085 740 8918

Within the last 2 weeks have you had problems with:

1. Fatigue

2. Sleeping

3. Poor Appetite

4. Nausea

5. Dizziness

6. Problems Conversing

7. A deterioration in your physical or mental condition

8. Breathlessness

9. Pain

10. A reduction in everyday functioning

11. Worrying

12. Restlessness

13. Feelings of loneliness or isolation

14. Feelings of sadness

15. Feelings of loss

16. Difficulty controlling your emotions

17. Diminished self confidence

18. Anxiety about illness or treatment

19. Feelings of depression

20. Feelings of despair

21. Have you had sufficient support around you

22. Would you have liked to talk to somebody