Questionnaire

Are you overwhelmed, stressed out, or having trouble coping? Many people today are having difficulty coping with something! In fact, more people than ever before are suffering from prolonged stress (from a variety of circumstances), one of the key villains in stress-related illnesses. The good news is that the Center for Coping has action-oriented methods and strategies which, when properly learned, can really help you to improve your quality of life… and enhance your well-being!

To help us determine the problems you’re dealing with and how well you’re coping with them, please complete the following “Personal Well-Being Evaluation" questionnaire. Then click the “send” button, and it will automatically be sent to one of our professionals for a thorough evaluation and interpretation of your well-being score.

The professional who evaluated your questionnaire will then contact you to set up a free, no-obligation appointment to discuss what your scores revealed and what your well-being level is. In addition, you'll receive valuable suggestions for things you can do to immediately start improving the quality of your life. This entire process is strictly CONFIDENTIAL and totally FREE OF CHARGE.

Of course, in order for us to provide you with a realistic and helpful evaluation, we ask that you answer the following questions honestly and accurately. Again, confidentiality is assured.


Now, take your first step to helping yourself!



Personal Well-Being Evaluation


Directions: Considering the timeframe of the past month, answer each of these questions as honestly and accurately as you possibly can. Answer quickly with the first answer that comes into your mind by clicking on the most appropriate circle.

   

Not at all

A little Somewhat A lot Totally
1 Are you experiencing any problems in your life right now?
2 Are you experiencing any job or school-related problems?
3 Are you experiencing financial problems?
4 Are you happy with your social relationships?
5 Is sleep a problem for you?
6 Are you happy with your family relationships?
7 Do others put you down?
8 Are you depressed?
9 Are you happy with things the way they are?
10 How much do you like yourself?
11 Are you satisfied with the activities that you are able to do?
12 Do you feel "stressed out"?
13 Are you satisfied with your ability to talk with others?
14 Are you angry?
15 Are you fearful or anxious?
16 How often do you criticize yourself?
17 Are any medical problems affecting you adversely?
18 Do you worry about things?
19 Do you use drugs or alcohol more than you should?
20 Do you think negative thoughts?

First Name
Last Name
Age
Phone
E-mail

Please indicate how you would like to be contacted:
Phone......... E-mail