Stress Help Center Success! You are about to start receiving your FREE* program.* If you'd like to rate yourself, BEFORE & AFTER, please answer the questions below. It is not a requirement to fill out the form in order to start the program. It is for your benefit only. Remember to look in your INBOX or SPAM mail for the confirmation email so that we make sure that you are really the person to request the program. Life may not Change but your Attitude WILL!
Name:
Email:
To what degree do you feel out of control in your life:
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme
How much has inadequate feeling been part of your experience:
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme
How anxious are you feeling with regard to your present circumstance:
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme
How depressed do you feel:
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme
How has your sexual relationship been affected (if applicable):
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme
To what extent has friendship been strained:
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme
To what extent do you feel angry:
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme
To what extent has your social interaction been affected:
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme
To what extent do you feel guilt:
1 None
2 Mild
3 Moderate
4 Severe
5 Extreme