New Client Questionnaire Name * First Name Last Name Email * Phone (###) ### #### I feel confident in my ability to regulate my emotions and reactions to anxiety, sadness, or anger. Always Most of the time Some of the time Seldom Never I have tools to manage my emotional and physical health, and I use them. Always Most of the time Some of the time Seldom Never I feel bored, numb, or apathetic. Always Most of the time Some of the time Seldom Never I am optimistic and excited about the future. Always Most of the time Some of the time Seldom Never I have goals that I am pursuing, and I am confident in my ability to reach them. Always Most of the time Some of the time Seldom Never Rank the following statements on a scale of 1-10, 1 being worst, ten being best. My relationship with my spouse My relationship with my kids My relationship with my family My relationship with my co-workers I think my biggest challenge in leadership or life right now is… If I could fix one relationship that would improve my life, it would be my relationship with… My biggest worries and anxieties seem to be about… One area of growth I would like to focus on is… Thank you!
