Name*

First Last

Email*

Do you lose many arguments and throw in the towel?*

Do you tend to want to please others and then let them walk over you?*

Do you feel depressed?*

Are you anxious on a regular basis?*

Do you get angry and/or have a short fuse?*

Do you regularly feel frustrated?*

Do you feel hopeless?*

Are your feelings causing you to implode and self-harm or addict?*

Do you stutter, have paranoia or phobias?*

Do you procrastinate and put off getting things done?*

Do you feel that you cannot remember important things?*

Do you feel betrayed and disappointed by others in any way?*

Do you suffer from insomnia?*

Are you going through grief or bereavement?*