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Menu
Homepage
About Us
Values
Cogwheel Today
Origins of Cogwheel
The Team
Trustees & Patrons
Charity Policies
Counselling
Families
Adults
Children
Young People
Relationships
Employee Counselling Service
Work With Us
Counselling Placements
Vacancies
Volunteer
Support Us
Ways to Donate
Fundraising
Businesses
Events Calendar
Other Ways to Help
Our Supporters
News
2019 Annual Report
Cogwheel Newsletters
Information & Support
Support & Services in Cambridge
Supporting Children and Young People
Get Urgent Help
Support & Coronavirus
Homepage
About Us
Values
Cogwheel Today
Origins of Cogwheel
The Team
Trustees & Patrons
Charity Policies
Counselling
Families
Adults
Children
Young People
Relationships
Employee Counselling Service
Work With Us
Counselling Placements
Vacancies
Volunteer
Support Us
Ways to Donate
Fundraising
Businesses
Events Calendar
Other Ways to Help
Our Supporters
News
2019 Annual Report
Cogwheel Newsletters
Information & Support
Support & Services in Cambridge
Supporting Children and Young People
Get Urgent Help
Support & Coronavirus
Menu
Homepage
About Us
Values
Cogwheel Today
Origins of Cogwheel
The Team
Trustees & Patrons
Charity Policies
Counselling
Families
Adults
Children
Young People
Relationships
Employee Counselling Service
Work With Us
Counselling Placements
Vacancies
Volunteer
Support Us
Ways to Donate
Fundraising
Businesses
Events Calendar
Other Ways to Help
Our Supporters
News
2019 Annual Report
Cogwheel Newsletters
Information & Support
Support & Services in Cambridge
Supporting Children and Young People
Get Urgent Help
Support & Coronavirus
Questionnaire
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I understand that, by completing and submitting these forms, I am consenting to Cogwheel holding my details in order to arrange a counselling assessment for me
Name
*
First
Last
Email Address
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1) I have felt terribly alone and isolated
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0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
2) I have felt tense, anxious or nervous
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0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
3) I have felt I have someone to turn to for support when needed
*
4 - Not at all
3 - Only occasionally
2 - Sometimes
1 - Often
0 - Most or all the time
4) I have felt O.K about myself
*
4 - Not at all
3 - Only occasionally
2 - Sometimes
1 - Often
0 - Most or all the time
5) I have felt totally lacking in energy or enthusiasm
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
6) I have been physically violent to others
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
7) I have felt able to cope when things go wrong
*
4 - Not at all
3 - Only occasionally
2 - Sometimes
1 - Often
0 - Most or all the time
8) I have been troubled by aches, pains or other physical problems
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0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
9) I have thought of hurting myself
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0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
10) Talking to people has felt too much for me
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0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
11) Tension and anxiety have prevented me doing important things
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
12) I have been happy with the things I have done
*
4 - Not at all
3 - Only occasionally
2 - Sometimes
1 - Often
0 - Most or all the time
13) I have been disturbed by unwanted thoughts and feelings
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
14) I have felt like crying
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
15) I have felt panic or terror
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
16) I made plans to end my life
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
17) I have felt overwhelmed by my problems
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
18) I have had difficulty getting to sleep or staying asleep
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
19) I have felt warmth of affection for someone
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4 - Not at all
3 - Only occasionally
2 - Sometimes
1 - Often
0 - Most or all the time
20) My problems have been impossible to put to one side
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
21) I have been able to do most things I needed to do
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4 - Not at all
3 - Only occasionally
2 - Sometimes
1 - Often
0 - Most or all the time
22) I have threatened or intimidated another person
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
23) I have felt despairing or hopeless
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
24) I have thought it would be better if I were dead
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
25) I have felt criticised by other people
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0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
26) I have thought I have no friends
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0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
27) I have felt unhappy
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
28) Unwanted images or memories have been distressing me
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
29) I have been irritable when with other people
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
30) I have thought I am to blame for my problems and difficulties
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
31) I have felt optimistic about my future
*
4 - Not at all
3 - Only occasionally
2 - Sometimes
1 - Often
0 - Most or all the time
32) I have achieved the things I wanted to
*
4 - Not at all
3 - Only occasionally
2 - Sometimes
1 - Often
0 - Most or all the time
33) I have felt humiliated or shamed by other people
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
34) I have hurt myself physically or taken dangerous risks with my health
*
0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time
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