Please enter your client number

1. Which organisation do you work for??

2. What is your role at work?

3. How would you describe your ethnicity?

4. How would you describe your main issue/problem?

5. How would you describe, briefly any other issues/problems?

Please highlight number which best describes your answer.
10=agree very much. 1=Do not agree at all - or some position between.

1. I have difficulty saying, "No"

2. I have difficulty asserting myself

3. I am not very good at maintaining boundaries

4. I don’t get much “me” time

5. I feel stressed a lot of the time currently

6. I do not have a good work life balance

7. I enjoy caring for others

8. I dislike conflict

9. I have good self-esteem

10. If things go wrong I usually blame myself

11. I dislike change

12. I do not like to be seen as vulnerable