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Self-Esteem

Assessment


Our Client Intake and Assessment Forms are designed to assist us in knowing more about you, your background, and what specific needs you wish to address.   Any information received from these forms will be used for the expressed purpose of assisting you in achieving your desired goals and is strictly confidential.
DEMOGRAPHIC ASSESSMENT
5. Explain your depression treatment history
6. Explain your bipolar disorder treatment history
7. Explain your generalized anxiety treatment history
8. Explain your post-traumatic disorder stress treatment history
4. Select your ethnicity/racial group:
3. What is your marital status?
2. What is your gender?
1. What is your age?
1. In social situations, I have something interesting to say.
SELF-ESTEEM ASSESSMENT
Self-Esteem questions are presented below. Select one option for each question that comes closest to your answer.
6. People respect and like only those who are good looking, smart, witty, talented or rich.
2. Most people around me seem to be better off than I am.
3. I like being myself and accept myself the way I am.
4. I mess up everything I touch
5. When I see a good opportunity, I recognize it and seize it.
7. To me, success is not imperitive. The important thing is to try and do my best.
8. I deserve to be loved and respected.
9. Unlike others, I really have to go out of my way to make and keep a friend.
10. If someone ever falls in love with me, I better do my best to prove worthy, because it may well never happen to me again.
Have you ever sonsulted a professional about self-esteem issues?
Do people tell you that you should stand up for yourself?
How much of your personality would you change if you could?
How much of your apperance would you change if you could?
6. Explain your bipolar treatment history.
7. Please explain your generalized anxiety disorder treatment history.
8. Please explain your post-traumatic stress disorder treatment history.
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65 and above
No response
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I am divorced or separated
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I am widowed
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Black or African American
Hispanic or Latino
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