EM Therapy logo EM Therapy ← Back to Home

New Client

Client Evaluation Form

Please complete this short form so Elizabeth can prepare for your first consultation.

Briefly describe what you'd like support with. All information is strictly confidential.
Please list any medications you are currently taking, including dosage. Write "None" if not applicable.
If yes, please name the condition(s). Write "No" if not applicable.

Self-Assessment

For each statement below, please select Yes or No based on how you have been feeling recently.

I feel overwhelmed by my responsibilities and don't cope well under pressure.
I lack self-confidence and often feel inferior or guilty.
I neglect my own needs to complete a task and feel emotionally drained.
I feel devastated due to recent shocks or trauma.
I struggle to forgive and forget, harboring bitterness or resentment.
I feel extreme mental or emotional heartache and hopelessness.
I overwork despite exhaustion due to a strong sense of duty.
I feel life is unfair and often have a "poor me" attitude.
I feel anxious without knowing why or fear that something bad will happen.
I sometimes feel terror or panic, including nightmares.
I am shy, overly sensitive, and modest in social situations.
I am overly concerned and worried about my loved ones.
I become helpless or frozen when afraid.
I fear losing control or feel like I'm going crazy.
I often hide my feelings and give in to avoid conflict.
I turn to food, work, or other coping mechanisms when down.
I find it difficult to say "no" and am easily influenced by others.
I feel discontented and unhappy in daily life.
I am suspicious of others or feel drained by social situations.
I want to pursue my own ambitions but feel trapped by circumstances.
I feel disconnected and often prefer to be alone when overwhelmed.
I am obsessed with my own troubles and find it hard to connect with others.
I dislike being alone but feel isolated in social interactions.
I am impatient, irritable, or find it hard to wait for things.
I often give the impression that I am aloof.
I keep repeating the same mistakes or wrong patterns.
I often feel spacey, absent-minded, or unable to concentrate.
I think more about the past or what might have been than the present.
I feel my moods swinging and often feel emotionally drained.
I have repeated unwanted thoughts and worries.
I relive unhappy events or arguments and have trouble letting go.
I struggle to sleep because I can't stop thinking.
I feel no joy in life and often feel apathetic or resigned.
I often criticize others or get annoyed by their habits.
I feel unappreciated by my family but strive for their approval.
I set very high standards for myself and am self-disciplined to a fault.
I am sensitive to injustice and feel strongly about correcting wrongs.
I try to take control of projects or situations but feel burdened by them.
I want to be a leader but often find myself overwhelmed by responsibility.
I constantly second-guess myself and change my mind out of confusion.
I feel discouraged by setbacks and often procrastinate.
I lack faith that things could get better and feel stuck in life.
I have intense mood swings and find it hard to make decisions.
I feel like I lack direction or a clear path in life.
I am ambitious but unsure how to achieve my goals.
Self-Assessment Score
0 / 45 Yes answers
0%

Your information is treated with the utmost confidentiality and will only be used to prepare for your consultation.