CCMCS Counselling Questionnaire

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

7

5. I have felt I have someone to turn to for support when needed. * This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

9

7. I have felt totally lacking in energy and enthusiasm* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

11

9. I have felt able to cope when things go wrong* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

12

10. I have been troubled by aches, pains, or other physical problems* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

14

12. Talking to people has always felt too much for me* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

15

13. Tension and anxiety have prevented me from doing important things* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

16

14. I have been happy with the things I have done* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

17

15. I have been disturbed by unwanted thoughts and feelings* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

18

16. I have felt like crying. I have felt criticized by other people* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

19

17. Unwanted imaged or memories have been distressing me* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

20

18. I have I thought it would be better if I were dead* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

21

19. I have been irritable when with other people* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

22

20. I have thought I am to blame for my problems and difficulties* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

25

23. I have felt humiliated or shamed by other people* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

26

24. I have hurt myself physically or taken dangerous risks with my health* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

27

25. Do life changes and events affect your personal well-being? * This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

28

26. Do you struggle to cope with challenging or difficult situations?* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

29

27. Would you say you can connect with your family or friends for support? * This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

30

28. Are you currently taking any medications for mental health or emotional well-being? * This field is required.

YESNO

31

29. Would you say you get good quality sleep every day throughout the week? * This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

32

30. How often do you get obsessive or intrusive behaviours* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

35

33. Would you regard yourself as someone with drive and motivation?* This field is required.

Not at all

Occasionally

Sometimes

Often

All the time

36

Have you been diagnosed with any mental health issues* This field is required.

Yes

No

37

Terms and Conditions* This field is required.