IoBM Wellness Center
Any information provided here is secure and is not accessible by any unauthorized personnel. The only people other than you who can access this information is IoBM’s Mental Health Counsellor. Therefore, be confident that your privacy is ensured.
Name
*
First Name
Last Name
Age
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Gender
*
Male
Female
Marital Status
*
Single
Married
Divorced
Employed
*
Yes
No
Have you attended any session earlier?
*
Yes
No
Which of the following modes of therapy are you comfortable with?
*
Individual
Group
Either Individual or Group
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Nature of Your Current Issue
Please complete the test (questionnaire) with your true feelings and mental state. It will help us to devise a meaningful treatment /support plan for you. After completing the test you will be guided through email about your next course of action that leads to your appointment with a therapist
Please select one
*
Regular disturbance relating to thoughts and emotions
Uncomfortable feelings relating to self and environmental conditions
Apprehensions relating to learning (classes/courses), exams, and/or degree
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Questionnaire
Numbness or tingling
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Feeling hot
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Wobbliness in legs
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Unable to relax
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Fear of worst happening
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Dizzy or lightheaded
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Heart pounding/racing
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Unsteady
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Terrified or afraid
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Nervous
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Feeling of chocking
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Hands trembling
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Shaky/unsteady
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Fear of losing control
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Difficulty in breathing
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Fear of dying
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Scared
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Indigestion
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Faint/Lightheaded
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Face flushed
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Hot/Cold Sweats
*
Not at all
Mildly - but it didn't bother me much
Moderately - it wasn't pleasant at times
Severely - it bothered me a lot
Little interest or pleasure in doing things
*
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed or hopeless
*
Not at all
Several days
More than half the days
Nearly every day
Trouble falling or staying asleep, or sleeping too much
*
Not at all
Several days
More than half the days
Nearly every day
Feeling tired or having little energy
*
Not at all
Several days
More than half the days
Nearly every day
Poor appetite or overeating
*
Not at all
Several days
More than half the days
Nearly every day
feeling bad about yourself - or that you are a failure or have let yourself or your family down
*
Not at all
Several days
More than half the days
Nearly every day
Trouble concentrating on things, such as reading the newspaper or watching television
*
Not at all
Several days
More than half the days
Nearly every day
Moving or speaking so slowly that other people could have notice, or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
*
Not at all
Several days
More than half the days
Nearly every day
Thoughts that you would be better off dead, or of hurting yourself
*
Not at all
Several days
More than half the days
Nearly every day
What are your top 2-3 concerns/reasons for seeking therapy?
*
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Degree Related Concern
Please state your concerns
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Appointment
What is your preferred medium of counseling?
In-person
Online
Appointment
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