Well-Being Self-Assessment

Well-Being Self-Assessment

(not for diagnosis)
This Self-Assessment is for Clients and New Clients. Assists Coach to gain insight on current status and progress. This self-assessment does not email results to your email like the Stress and PTSD Self-Test/Self-Assessment.
Name

First NameLast Name
Email
example@example.com

Rate the Intensity Level (0=Not an Issue, 10=Very Intense) you are EXPERIENCING:

Rows	#
Abandonment
Anxiety
Anger
Abuse-Emotional
Abuse-Physical
Abuse-Sexual
Addiction
Addiction (food)
Betrayal
Codependency
Depression
Emotional Eating
Emotional Instability
Energy (low)
Fear
Flashbacks
Grief
Guilt
Hearing Voices
Hot flashes
Insomnia
Loneliness
Loss
Nagging Thoughts
Negative Thinking
Night Terrors
Occult
OCD/Compulsive
Panic Attacks
Phobia
Pain
Pain (Chronic)
Procrastinating
PTSD
PISD (from some form of infidelity)
Rage
Rejection
Repetitive Dreams
Shame
Suicidal
Suicidal Thoughts
Stress
Stress (Chronic)
Torment
Trauma
Triggers
Unwanted Behavior
Worry
Cycle/Patterns (job loss, relationships, etc.)
Something Dark
Something Else

PART B - LIFE SATISFACTION

Life Satisfaction Level. Rate on scale of 0-10 (0=Not an Issue, 10=Very DisSatisfied)

Rows	#
Physical Environment
Business/Career
Finances
Health
Family
Friends
Romance
Personal Growth
Fun and Recreation
Emotional
Spiritual

Comments
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