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Independence vs Interdependence - INTAKE
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Name
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First Name
Last Name
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Email
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Phone Number
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4
How much do you feel that this statement applies to you: “Growing up, I was always the ‘most promising’ or ‘gifted’ one. Now, as an adult, I feel like I’ve wasted all that potential.”
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Does not apply to me at all
Strongly applies to me
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5
Do you often find yourself comparing yourself to others?
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Yes – but I try not to let it get to me.
Yes – and it often makes me feel horrible.
No – I know it would only make me feel bad if I did.
No – I don’t see why I should.
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6
If your closest friend at work were to get a huge promotion today, which of the following best describes how it would make you feel?
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Great – they deserve it, and seeing them happy makes me happy, too!
Okay – good for them. I guess I’ll just have to work harder.
Indifferent – it doesn’t really have anything to do with me.
Awful – looks like I’ve failed… AS USUAL.
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7
What area of your life do you feel the most unhappy with? Why do you think that is?
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8
If you met a good fairy, who offered to grant you one wish pertaining to succeeding in life, what would that wish be?
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9
Is there anything else you feel is important for the therapist to know before we start the chat?
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