Family quiz | Watershed Counselling

What type of family are you living in?*

Nuclear (mother, father, child)

Single Parent (either father or mother and at least one child)

Blended (single parent marries another person who may or may not have children)

Extended (mother and father, at least one child, other relatives)

Other

What is your gender?*

Male

Female

Transgender

Non-binary/Non-conforming

Other

How many members are in there in your family?

How do you identify?*

What is your relationship status?*

Do you consider yourself religious?*

Yes

Which religion do you identify with?*

Christianity

Judaism

Islam

Other

Do you consider yourself spiritual?*

Yes

Have you ever been in therapy before?*

Yes

When was the last time you tried to communicate with your family?*

Last week

Last month

Over 3 months ago

Over 6 months ago

Other

In terms of your physical health, how would you rate it?*

Good

Fair

Poor

How would you rate your current eating habits?*

Good

Fair

Poor

Do you feel overwhelmed with sadness, grief, or depression at the moment?*

Yes

How often have you been bothered by any of the following during the past two weeks: There is little interest or pleasure in doing things.*

Not at all

Over several days

More than half the days

Almost every day

How often have you been bothered by any of the following during the past two weeks: Are you moving or speaking so slowly that other people may have noticed? Or the opposite-moving around a lot more than usual because you are restless or fidgety.*

Not at all

Over several days

More than half the days

Almost every day

How often have you been bothered by any of the following during the past two weeks: Having a feeling of hopelessness or depression*

Not at all

Over several days

More than half the days

Almost every day

How often have you been bothered by any of the following during the past two weeks: Not being able to fall asleep, staying asleep, or sleeping too much.*

Not at all

Over several days

More than half the days

Almost every day

How often have you been bothered by any of the following during the past two weeks: Having little energy or feeling tired*

Over several days

More than half the days

Almost every day

How often have you been bothered by any of the following during the past two weeks: Overeating or poor appetite*

Not at all

Over several days

More than half the days

Almost every day

How often have you been bothered by any of the following during the past two weeks: Feeling unsatisfied with yourself, or feeling like you have let yourself and your family.*

Not at all

Over several days

More than half the days

Almost every day

How often have you been bothered by any of the following during the past two weeks: Concentration problems, such as watching TV or reading the newspaper?*

Not at all

Over several days

More than half the days

Almost every day

How often have you been bothered by any of the following during the past two weeks: The idea that you would be better off dead or hurting yourself.*

Not at all

Over several days

More than half the days

Almost every day

How often have you been bothered by any of the following during the past two weeks: How difficult is it for you to work, take care of things at home, or get along with others because of these problems?*

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Are currently employed?*

Yes

Is intimacy a problem or concern for you?*

Yes

What is your frequency of alcohol consumption?*

When was the last time you considered suicide?*

Never

Over a year ago

Over 3 months ago

Over a month ago

Over 2 weeks ago

In the last 2 weeks

Who do you communicate your needs with?*

My friends

My partner

No-one

Rent a family/Dating sites

Other

Can you tell me if you are currently suffering from anxiety, panic attacks, or phobias?*

Yes

Do you currently take any medications?*

Yes

Do you currently experience chronic pain?*

Yes

In what way would you rate your current financial situation?*

Good

Fair

Poor

In what way would you rate your current sleeping habits?*

Good

Fair

Poor

If you were in therapy, how would you like to experience it?*

Online(Zoom)

Face to face

Not sure

Your Introduction

After submitting your personal details you will be directed to our booking calendar!

Your Name*

Your Email*

Your Phone*

Help us understand your needs and how we can help your family!

Please fill out this short quiz to give us some contextual information about your family.

Your Introduction