Pre-Therapy Screening – Personal Solutions Counseling

Instructions: Please respond to every statement on the left side of the screen by selecting one option below that statement. You can use your tab button on your keyboard to move from one drop down list to the next. The further down each drop down list, the MORE TRUE you find the statement. Some statements you may believe to be only partially true, so there are options between true and false.

First Name *

Last 4 digits of your phone number *

1) Being loved and in love with someone will make me happy and improve my self esteem. *

2) I am comfortable when I think other people are judging me or disapprove of me. *

3) I have to wait to get in the mood to do something. *

4) When I'm angry or irritated with someone, I tend to hold it in or keep it to myself. *

5) I don't have much hope about my situation or my problems. *

6) I shouldn't have to deal with certain things. I shouldn't just wait for things to get better. *

7) People seem bossy or demanding. *

8) If I can't do things perfectly, then I might as well not do them at all, or wait until I have time to do them perfectly. *

9) My moods are mostly out of my control. *

10) I feel like people are bossy or demanding and they make me get defensive. *

11) I don't want to ask anyone for help. Asking someone to help me with personal problems seems weak or even stupid. *

12) I am over commited - I have too much to do - I shouldn't take on anything else. *

13) It's unfair for me to have to be the one that makes changes for things to get better. *

14) My mood problems or anxiety is caused by a chemical imbalance of some sort. *

15) I have problems that I am afraid or reluctant to share with the therapist. *

16) I have difficulty tolerating frustration. I don't have much patience. *

17) I'm here because someone else important to me wants me to be here. *

18) I'm not willing to do therapy "homework." I just need to talk to someone and get it all out. *

19) I have alot going on and don't even know where to begin. *

20) I have alot of feelings to vent, and alot of issues to deal with. I don't want to focus on one thing. *

21) I'm not ready to change my behavior. *

22) I don't want someone to give me advice. *

23) I don't want someone to challenge my beliefs about issues. *

24) Sometimes I think that I like to feel miserable. *

25) There's no way I can work through my problems in a short period of time. I think that I will need to be in therapy quite awhile. *

26) I should have a better life than I do. I feel like I've been cheated out of good things, things I deserve, really. *

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