All entries on this form are confidential and will help our Counsellors have a background knowledge of your person. Please complete with the accurate information. Thank you! Firstname * Lastname * Email Address * Phone Number * Gender * FemaleMaleOthers I usually feel sad and unhappy about my life and experiences * RarelySometimesOftenAlways I am usually very worried about how my life will turn out * RarelySometimesOftenAlways I believe I can't make it * RarelySometimesOftenAlways I believe in my ability to build a sense of personal strength as I go through life * RarelySometimesOftenAlways I am usually very fast in recovering from challenges and difficulty * RarelySometimesOftenAlways I blame myself for what has happened to me * RarelySometimesOftenAlways I get tensed and agitated when I have to do things * RarelySometimesOftenAlways I often relive or re-experience traumatic events when I'm alone * RarelySometimesOftenAlways I have difficulty achieving my goals no matter how much I try * RarelySometimesOftenAlways Making decisions about my life is often difficult for me * RarelySometimesOftenAlways Do you have Children? * YesNo How Many? Submit