(The data collected will be used only for counselling, therapy and research purpose without disclosing the identity of the client. Confidentiality of data is assured. Please answer all the questions. If you don't want to disclose any details please mention it.)
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Name/Nick name *
1) Mention a few of your positive qualities and skills *
2) How do you perceive yourself, An extrovert / an introvert/ depends on situation/other *
3) Are you satisfied with your present physical attractiveness (Yes/ No/   *
4) Do you experience mood swings quite often? (feeling high and low alternatively) *
5) Do you have obsessive thoughts(recurring thoughts) and worries? If so the type of thought. *
6) How satisfied is your marital life? (on a scale of 0 to10. 1 least satisfied to 10 highly satisfied)(If you are married) *
7) Do you do regular exercise? *
8) Select the words that best suits your physical and psychological state. (Choose any number of words. Write the most intense feelings to the least ones.)   lonely, anger, guilty, shame, depressed, fearful, phobic, anxiety, confused, irritated, revengeful, tensed, lack of time, feeling extremely high/low mood, highly sensitive, difficulty to adjust, low self-image/worth, hallucination, obsessive thoughts etc.( may use other words too) *
9) Do you find difficulty to approach and talk to the members of the opposite sex? If yes, how intense it is on a scale of 1 to10.
9) Have you gone for counselling/therapy for the current problem or for any other related  problems earlier?( Yes, No) If yes mention details. *
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