Counseling Questionnaire
* Required
Name
*
Your answer
Age
*
Your answer
Email Address
*
Your answer
Phone Number
*
Your answer
City of Residence
*
Your answer
I feel anxious most of the time.
Yes
No
Clear selection
I don't know why I cannot achieve the goals I have set.
Yes
No
Clear selection
I feel like I have let people down.
Yes
No
Clear selection
People have rejected me in the past.
Yes
No
Clear selection
I would prefer to meet with a Counselor instead of my family members to assist me with these emotional needs.
Yes
No
Clear selection
What questions do you have about Counseling?
Your answer
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