Please complete this questionnaire at the beginning of your session.

Please write down one or two issues or concerns you'd most like our help with.

Please use the scale to show how severe Concern 1 is to you at this moment. 

Please use the scale to show how severe Concern 2 is to you at this moment. 

How would you rate your overall emotional wellbeing at this moment?

All information is strictly confidential and stored inline with the Data Protection Act 1998 and GDPR regulations.

Thanks for submitting!