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admin@cogwheel.org.uk

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- 2019 Annual Report
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Menu

Homepage
About Us
Counselling
Work With Us
Support Us
News
- 2019 Annual Report
- Cogwheel Newsletters
Information & Support

Homepage
About Us
Counselling
Work With Us
Support Us
News
- 2019 Annual Report
- Cogwheel Newsletters
Information & Support

Menu

Homepage
About Us
Counselling
Work With Us
Support Us
News
- 2019 Annual Report
- Cogwheel Newsletters
Information & Support

Questionnaire

Consent Checkbox *

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 *

1) I have felt terribly alone and isolated *

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 *

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 *

0 - Not at all
1 - Only occasionally
2 - Sometimes
3 - Often
4 - Most or all the time

9) I have thought of hurting myself *

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 *

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 *

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 *

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 *

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 *

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

Email

A Cambridge-based organisation with hubs in Sawston and Ely that provides affordable professional counselling to the community. We ask people to make a regular financial contribution towards their counselling.

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Contact Info

47-51 Norfolk Street, Cambridge, CB1 2LD

Phone: 01223 464385

Email: admin@cogwheel.org.uk

Web: www.cogwheel.org.uk

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