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Client self-assessment form

Emotional Well-being Self-Assessment

Your focus: Sleep Quality Results across all 8 areas

Past 2 weeks Answers stay on this device

Before you begin

About you

Instructions

Think about the past 2 weeks

Choose the answer that best describes your experience. There are no right or wrong answers; answer honestly based on how you have felt recently.

0Not at all
1Occasionally / a little
2Often / quite a lot
3Almost every day / very much
0 of 20 answered
01Depression

1I have lost interest or pleasure in activities that I usually enjoy.

2I have been feeling sad, empty, low, or hopeless.

3I feel tired or lack energy even after resting.

02Anxiety

4I feel nervous, worried, or uneasy without a clear reason.

5I find it difficult to control or stop worrying.

6I notice physical signs of anxiety, such as a racing heart, trembling, breathlessness, or stomach discomfort.

03Stress

7I feel under pressure or overwhelmed by my responsibilities.

8I find it difficult to relax, even when I have time to rest.

9I become irritated, impatient, or emotionally overwhelmed easily.

04Burnout

10I feel emotionally or physically exhausted by the demands in my life.

11I feel I have less energy, motivation, or capacity than I used to.

05Sleep Quality

12I have difficulty falling asleep, staying asleep, or wake earlier than I want to.

13My sleep does not leave me feeling rested or restored.

06Self-Esteem

14I have been critical of myself or felt that I am not good enough.

15I have felt worthless, guilty, or like a failure.

07Social Anxiety

16I feel very self-conscious or fear being judged around other people.

17I avoid people, conversations, or situations because they make me anxious.

08Emotional Well-being

18I find it difficult to manage strong emotions when they arise.

19My emotional state interferes with my concentration, relationships, or daily activities.

20I have felt disconnected from myself, other people, or the things that give my life meaning.

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