Crossroads Counseling Center - Clermont, Florida

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Survey

Rate the items with which you are currently having problems. Choose the number that best indicates the seriousness of the problem.

0 = none, 1 = almost none, 2 = some problem, 3 = moderate problem, 4 = significant problem, 5 = serious problem

	0	1	2	3	4	5
Anxiety Problems
Depression, Sadness or Mood Disorders
Thoughts of Death (i.e.Suicidal)
Nervousness, Sleep or Anger Problems
Feelings of Panic/Fear
Grief over the death of a loved one or major loss
Physically or Emotionally Abused as a Child
Sexually Abused as a Child
Parent(s) had Alcohol or Drug Problems
Parent(s) had Emotional or Marital Problems
Loss of Love, Hope or Self Respect
Loss of Faith in Others
Loss of Faith in God
Feelings of Guilt/Shame
Marriage Problems
Relationship Problems with Children
Problems with Parents or Family
Work, School or Legal Problems
Sexual Concerns/Problems
Eating, Weight or Habit Problems
Alcohol, Drug, Smoking or Other Addictions
Feelings of Hopelessness, Helplessness, or Despair

Request an appointment time to meet with Dr. Al Huba or one of the Crossroads Counseling Center Staff