The Psych Wellbeing | Emotional Wellbeing Check-in

🌸 A gentle note: This is a self-reflection tool, not a diagnosis or medical assessment. It helps you notice how you've been feeling over the past week. Your answers will be shared with your psychologist to support your wellbeing journey.

Your Name

Date of reflection

psychologist / Counsellor

Rating scale (over the past week):
0 = Did not apply to me at all 1 = Applied to me to some degree, or some of the time 2 = Applied to me to a considerable degree, or a good part of the time 3 = Applied to me very much, or most of the time

#	Statement	1	2	3
1	I found it hard to wind down	1	2	3
2	I was aware of dryness of my mouth	1	2	3
3	I couldn't seem to experience any positive feeling at all	1	2	3
4	I experienced breathing difficulty (e.g., excessively rapid breathing)	1	2	3
5	I found it difficult to work up the initiative to do things	1	2	3
6	I tended to over-react to situations	1	2	3
7	I experienced trembling (e.g., in the hands)	1	2	3
8	I felt that I was using a lot of nervous energy	1	2	3
9	I was worried about situations in which I might panic and make a fool of myself	1	2	3
10	I felt that I had nothing to look forward to	1	2	3
11	I found myself getting agitated	1	2	3
12	I found it difficult to relax	1	2	3
13	I felt down-hearted and blue	1	2	3
14	I was intolerant of anything that kept me from getting on with what I was doing	1	2	3
15	I felt I was close to panic	1	2	3
16	I was unable to become enthusiastic about anything	1	2	3
17	I felt I wasn't worth much as a person	1	2	3
18	I felt that I was rather touchy	1	2	3
19	I was aware of the action of my heart in the absence of physical exertion	1	2	3
20	I felt scared without any good reason	1	2	3
21	I felt that life was meaningless	1	2	3

📊 Summary of responses — for psychologist use only

Scale 1:
0

Scale 2:
0

Scale 3:
0

These scores help your psychologist understand your experience. They are not a diagnosis.