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Therapeutic Gems: Is it Time for Support?

Name

*

Email Address

*

State

*

Lately, how often have you felt emotionally overwhelmed?

*

1

Rarely

2

Sometimes

3

Often

4

Very Often

Have stress, anxiety, sadness, or irritability been affecting your daily life?

*

1

Not really

2

A Little

3

Yes, somewhat

4

Yes, Significantly

Do you find yourself repeating patterns in relationships, work, or personal decisions that you want to change?

*

1

No

2

Maybe once in a while

3

Yes

4

Yes, and I feel stuck

How comfortable are you with talking about your thoughts, feelings, or life experiences with a professional?

*

1

Not comfortable at all

2

Somewhat comfortable

3

Unsure, but open to trying

4

Very Comfortable

Are you looking for support with any of the following?

*

Stress management

Anxiety

Depression or low mood

Life transitions

Relationship concerns

Trauma or past experiences

Self-esteem

Emotional regulation

Other

Do you want a space where you can process your thoughts without judgment?

*

1

No

2

Maybe

3

Yes

4

Absolutely

Have you been feeling "off", even if you cannot fully explain why?

*

1

No

2

A Little

3

Yes

4

Very Much So

Are you open to learning coping tools, new perspectives, or healthier patterns?

*

1

No

2

Somewhat

3

Yes

4

Definitely

Have friends, family, or others suggested that talking to someone might help?

*

1

No

2

Once or twice

3

Yes

4

Yes, more than once

What do you need the most right now?

*

After taking this quiz, do you think you could benefit from therapy?

*

A

Yes, I think I could benefit from therapy

B

Somewhat; I am not sure

C

Not really