Anxiety Assessment


Please provide the following contact information (email essential):

Your full name:

Email address:

Birthdate (day/month/year)

Gender (Male/Female)


The Format of profiling your experience of ANXIETY is 

1. WHEN (you identify the triggering or activating events)

2. I FEEL (you identify the level of impact that accompanies ANXIETY)

3. I RESPOND BY (you identify the behaviours or actions that accompany you feeling ANXIETY)

4. BECAUSE (you identify the thinking that accompanies the experience of ANXIETY)


WHEN

I am facing a threat
I am facing a danger
I am facing a challenge

Other WHENs

I experience FEELINGS associated with Anxiety

to this level 

I RESPOND BY

Warding off the threat [event] with ritual, superstition etc.
Tranquilising my feelings with medication or substances.
Seeking reassurance from others

          Taking medication prescribed by a medical professional

Other Responses you make

BECAUSE

I overestimate the negative features of the (event)
I underestimate my ability to cope with the threat
I create an even more negative threat in my mind
I have more task irrelevant thoughts than mere concern
I withdraw mentally from the [event]

I withdraw physically from the [event]
Other Becauses

Please add comments you feel I need to know to understand you and your experience of anxiety?