Step 1 of 20 - Step 1 0% CommentsThis field is for validation purposes and should be left unchanged.Register / LoginName First Name Last Name Email(Required) Mobile NumberDate of Birth DD dash MM dash YYYY Address Home Address Doctor’s surgery address Your Partner InformationName First Name Last Name Email(Required) Mobile NumberDate of Birth DD dash MM dash YYYY Address Home Address Doctor’s surgery address Thank you for registering and logging in! You can head to our dairy and book an appointment. It’s a one-hour assessment at our dairy. Your health is essential to us, and we’d like to ask you a few questions to better understand your needs. Continue to Next StepDate DD dash MM dash YYYY Time Hours : Minutes AM PM AM/PM Couple Therapy Assessment Duration: Cost:Pay Now How have you been the last two weeks? Feeling nervous, anxious, or on edgea ? Not at all Several days More than half the days Nearly every day Not being able to stop or control worrying ? Not at all Several days More than half the days Nearly every day Worrying too much about different things ? Not at all Several days More than half the days Nearly every day Trouble relaxing ? Not at all Several days More than half the days Nearly every day Being so restless that it is hard to sit still ? Not at all Several days More than half the days Nearly every day Becoming easily annoyed or irritable ? Not at all Several days More than half the days Nearly every day Feeling afraid as if something awful might happen ? Not at all Several days More than half the days Nearly every day I have felt tense, anxious, or nervous. Not at all Only occasionally Sometimes Often Most or all the time I have felt I have someone to turn to for support when needed. Not at all Only occasionally Sometimes Often Most or all the time I have felt able to cope when things go wrong. Not at all Only occasionally Sometimes Often Most or all the time I have felt unhappy. Not at all Only occasionally Sometimes Often Most or all the time I have done most things I needed to. Not at all Only occasionally Sometimes Often Most or all the time We are near the end now. I have felt warmth or affection for someone. Not at all Only occasionally Sometimes Often Most or all the time I have had difficulty getting to sleep or staying asleep. Not at all Only occasionally Sometimes Often Most or all the time I have felt lonely. Not at all Only occasionally Sometimes Often Most or all the time I have felt I have made progress towards achieving my goals. Not at all Only occasionally Sometimes Often Most or all the time I have felt despair or hopelessness. Not at all Only occasionally Sometimes Often Most or all the time Δ
