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How are you doing?
This is completely anonymous and a chance for you to share any concerns, stresses, or general stuff about you. Please note, responses to this will never be shared.
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How's your mood been this week?
Good and steady
Ok - a bit up and down
All over the place!
Really low
Flying high
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Have you experienced any of the following this week? (tick all that apply)
Loneliness
Anxiety
Depression
Anger
Disordered thinking
Struggles with addiction
Shame
Grief
Regret
Guilt
Fear
Self-sabotage
Low self-esteem
Other
If other, please share if you wish...
Your answer
Is there any over-arching struggle you're dealing with right now?
Your answer
What do you think you need right now?
Your answer
Do you have someone you can be truly open and honest with about how you're feeling?
Yes
No
I do ...but I don't tend to open up
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Anything you want to anonymously vent?
Your answer
Are you currently seeing a therapist?
Yes
No
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