Denial Test Form

Denial Test Form

This form is to help determine how much denial you are experiencing
Do you have a problem?

YesNo (If no, why are you filling out this form? - answer below)Other
Do you ever experience anger, anxiety or depression?

Yes, all the timeYes, occasionallyNo, I don't careNo, I am a pretty even personOther
Do you have more than one problem?

YesNo, just one problem right nowNo, I don't have any issues (If no, why are you still here? - answer below)Other
Does your main problem involve other people?

NoYes (If yes, who? - answer below)Other
Do other people think you have a problem?

NoYes (If yes, who? - answer below)Other
If other people think you have a problem, what do they say to you?

Nothing, I can just tellNothing, I hear them talking behind my backThe voices in my head tell meOther
Do other people have a problem?

NoYes, they do tooYes, it's all their problem not mine
Is there someone who to blame for your problem?

No, it's just lifeYes, I amYes, someone else is (If yes, who? - answer below)Other
Are the problems you experience always someone else's fault?

No, neverNo, but sometimesYes, all the time
Have you tried everything you can think of to fix your problem?

Yes, it's hopeless, nothing works and nothing will ever workYes, but I am willing to try new thingsNo, but there are still a few things I can tryNo, but I am just sick of trying
Do you need to do something about your problem?

No, it won't helpNo, I'm not readyYes, I am ready and can handle it myselfYes, I am ready but need help
Are you willing to do something about your problem?

No, it's not that badYes (if yes, continue to answer questions, if no you may stop here)
Select all of the things that you are willing to do about your problem?

Talk with someone safeJournal / Write About ItImprove Self-CareContinue EducationGroup Therapy12 Step MeetingsTherapyExerciseRecovery ProgramSave MoneyChange BehaviorsPrayer / MeditationService WorkLet Go, Cry, Surrender, AcceptBe PatientAsk For HelpStand Up For YourselfLeave The SituationContact The AuthoritiesLegal ActionChange CareersInvest MoneyComplain to or about responsible partyNothing At All
Please describe your problem (s).
If this is an old issue, explain the first time it happened.
Who are you willing to speak with? (if other, please add their name and email address)

Jeff RoundsSelyna BreezeDavid WilkOther
Name

First NameLast Name
Email
example@example.com
By submitting I hereby confirm that the information I have given above is true, and that I will be receiving an email response to my submission and an invitation to discuss the results with a nonprofessional member of Mixed Recovery.
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