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 :

info@resolvenow.ie

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