Child Evaluation

Name

Last name

Your responses have been received. Thank you!

Tell me exactly, what do you want to achieve with therapy? What is your greatest wish?

What would your life be like without this issue? Be specific by expressing your feelings and wishes. How living without this issue would affect your personal, work, and social life?

How will you know that this issue is not part of your life anymore?

How is your childhood? Relationship with your parents, siblings, ...

Comments. If you want to add something else I am delighted to hear from you.

To what degree are the following possible symptoms showing up? Please score from 1 being the lowest to 10 being the highest.