Clarity - Cognitive Behavioural Therapy

ADDRESS: Clarity Insight Ltd, The Forum, Lansdown Road
Cheltenham, GL50 2JA. TEL: 01242 224 120

Could therapy help you?

There is no need to wait as initial assessments for Clarity CBT are available immediately without referral from a health professional

Assess your own needs for therapy by completing this simple questionnaire. Try not to spend too much time on each statement and be honest with yourself.

The questionnaire is in two sections. Section 1 covers what you think about yourself. Section 2 covers how you feel and behave.

The questions will help you to decide if a personal assessment of your needs would be beneficial. If you answer "yes" to more than half, or if any individual statement raises concern for you, an assessment with a Clarity therapist may help.

When you have completed the questionnaire we will make an initial assessment and respond within 5 working days.

Section 1: What you think about yourself

In general, people have not met my emotional needs, supported me or shown I am
special to them.

I sometimes worry that people I care about will leave, abandon or take advantage of me.

I can be suspicious of other people's motives and have difficulty trusting them.

I often feel different from others, isolated and alone.

I don't let other people see the real me very often.

Most other people I know are more capable and intelligent or achieve more than I do.

I often struggle to get by or cope on my own.

I sometimes feel as though something bad, unpleasant or difficult is about to happen.

I find it difficult to maintain any distance from people I am close to.

10.

I worry about pleasing other people because they might criticise, reject or leave me.

11.

I often put the needs of others before my own or I feel bad.

12.

A lot of anger, bitterness or resentment builds up inside me that I can't really express.

13.

I must meet all my responsibilities and be the best at most of what I do.

14.

Almost nothing I do is quite good enough; I can always do better.

15.

I get upset or irritable if I can't do or get what I want.

16.

Sometimes if I get angry or frustrated; I struggle to control it.

17.

It is important for me to be liked by almost everyone I know.

18.

People that know me consider me to be a worrier.

19.

I often think about mistakes I have made and feel let down or angry with myself.

20.

How I feel about myself is based on what others think about me and what I do.

Section 2: How you feel and behave

I just can't seem to get going some days.

I tend to overreact to situations or get upset easily.

I sometimes find myself in situations that make me so anxious I feel I need to leave
or get away.

I find it hard to sleep, relax or wind down.

I often feel alone or isolated.

I am tense, anxious or nervous a lot of the time.

I feel I often lack energy and enthusiasm.

I feel that I can't cope when things go wrong.

I am troubled by aches, pains or physical problems.

10.

My problems are hard to put to one side.

11.

I have felt hopeless or in despair at times.

12.

I feel I am to blame for my problems or difficulties.

13.

I often avoid doing things or making decisions in case I get them wrong.

14.

I often do things to avoid criticism or to gain approval from others.

15.

It is often easier to avoid my personal difficulties and responsibilities than to deal with them.

Please complete the following basic personal information and submit the form to Clarity for assessment and feedback. All information will be held in the strictest confidence and will not be shared, transmitted or exchanged. Fields marked with an asterisk* are essential.

Your Full Name*

Male

Female

Date of birth*

Email Address *

Telephone Number including area code

Any comments?

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