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Client Interview Form 3

Client Interview Form 3

August 20, 2024 Pearl

Pearl Therapy Preliminary Information Form-3

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Name Surname *

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Middle name

Surname

PEARL THERAPY INNER EMOTION ASSESSMENT FORM

Rate the following emotions between 0 and 10 according to how you generally feel.

0: You have never felt that emotion

10: It means you feel that emotion at the maximum level.

I Often Feel Worthless

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel ANXIOUS

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Powerless

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Hopeless

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Incompetent

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Pessimistic

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Uninspired

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Useless

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel ANGRY

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Inconsistent

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Inadequate

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Sad

0
1
2
3
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5
6
7
8
9
10

I Usually Feel UGLY

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Stressed

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Angry

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Unlovable

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Unhappy

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Restless

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Like a Failure

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Troubled

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Bored

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Unmotivated

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Numb

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Ordinary

0
1
2
3
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5
6
7
8
9
10

I Often Feel Unintelligible

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Unattractive

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel NERVOUS

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel SAD

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Antipathic

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Unimportant

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Angry

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel ANXIOUS

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Undecided

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel UNEXCITED

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Alone

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Fragile

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Incompatible

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Serious

0
1
2
3
4
5
6
7
8
9
10

I Often Feel ANXIOUS

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Tired

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Impatient

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Passive

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Bitter

0
1
2
3
4
5
6
7
8
9
10

I Often Feel Insecure

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel EXHAUSTED

0
1
2
3
4
5
6
7
8
9
10

I Often Feel EXHAUSTED

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Agitated

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel SCARED

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Bored

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel HURRY

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel PROBLEM

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Dull

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Despondent

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Unlucky

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Angry

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Absent-Minded

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Shy

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel SLOW

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Boring

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Stagnant

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Valuable

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel ANXIETY-FREE

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Strong

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Hopeful

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Skilled

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Optimistic

0
1
2
3
4
5
6
7
8
9
10

I generally feel PLEASANT

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Useful

0
1
2
3
4
5
6
7
8
9
10

I generally feel CALM

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Consistent

0
1
2
3
4
5
6
7
8
9
10

I generally feel adequate

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Joyful

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Beautiful

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Stress-Free

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Angry

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel CUTE

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Happy

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel PEACEFUL

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Successful

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Carefree

0
1
2
3
4
5
6
7
8
9
10

I generally feel FULL OF LIFE

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Desired

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Active

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel EXTRAORDINARY

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Understanding

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Attractive

0
1
2
3
4
5
6
7
8
9
10

I generally feel comfortable

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Cheerful

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel SYMPATHETIC

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel IMPORTANT

0
1
2
3
4
5
6
7
8
9
10

I generally feel comfortable

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Social

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Calm

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Determined

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Excited

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Resistant

0
1
2
3
4
5
6
7
8
9
10

I generally feel harmonious

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Playful

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel ANXIOUS

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Fit

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Patient

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Active

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Enthusiastic

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Safe

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Energetic

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Determined

0
1
2
3
4
5
6
7
8
9
10

I generally feel cool

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Brave

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Enthusiastic

0
1
2
3
4
5
6
7
8
9
10

I generally feel CALM

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Trouble-Free

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel BRIGHT

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel CRAZY

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Lucky

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Loving

0
1
2
3
4
5
6
7
8
9
10

I Generally Feel Careful

0
1
2
3
4
5
6
7
8
9
10

I generally feel enterprising

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel FAST

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Humorous

0
1
2
3
4
5
6
7
8
9
10

I Usually Feel Alive

0
1
2
3
4
5
6
7
8
9
10

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Published by Pearl

Pearl Therapy: Family counseling, marriage therapy, relationship coaching, subconscious therapy, psychologist, psychiatrist, dietitian, doctor, EFT, hypnosis, EMDR, regression, breathing, Turkish therapy, online appointment, face-to-face sessions, Belgium, Germany, France, Netherlands, England, America, Austria

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As a family (3 or more people)

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your Gender *

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Please select the session type you would like to make an appointment for;

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Holistic Subconscious Therapy Appointment
Holistic Master Therapy Appointment
Couple - Marriage Therapy / Family Counseling Appointment
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Get rid of all kinds of physical, psychological, family and sexual problems and addictions by clearing the main sources of the problems with Pearl Therapy's Holistic approach!

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Netherlands : +32 488 088905
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