Emotional well-being for adults

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Adult Emotional Wellbeing

Emotional Well-being for adults

Please note that this is a short form, more information would be necessary to make an accurate diagnosis. Once you have clicked on the submit button I will receive the information below via email. I can then contact you to discuss your emotional well-being further and provide you with possible options, if needed, that could address your unique concerns.

* Indicates required field

Do you experience any of the following? *

Anger outbursts Severe Sadness Mood swings A sense of hopelessness Struggle to concentrate Thoughts of harming yourself Other

How often would this occurr? *

Daily More than once a week Weekly Monthly Only once every couple of months

How long have you been experiencing the above mentioned? *

1-3 months 3-6 months 6-12 months 1- 2 years Longer than 2 years

Does your emotional well-being have a destructive impact on any of the following *

Significant relationships Work performance All of the above

If you would like to be contacted please provide me with either your email address or contact number *

Please provide me with any further information that is relevant to your emotional well-being *

Submit

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Home
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