First Name *

Last Name *

Email *

Take a few minutes to answer these questions honestly. For each statement, rate how often you’ve felt this way in the past two weeks:

0 = Never

1 = Rarely

2 = Sometimes

3 = Often

4 = Always

I feel physically and emotionally drained, even after a good night’s sleep. *

I find it hard to concentrate or make simple decisions. *

I’ve lost interest in activities I usually enjoy. *

I feel irritable or snap at others more than usual. *

I experience headaches, stomach issues, or unexplained aches and pains. *

I feel detached or disconnected from friends, family, or colleagues. *

I feel overwhelmed by my responsibilities, even small tasks. *

I struggle to motivate myself to get started in the morning. *

I feel like I’m just “getting by” rather than thriving. *

I find myself withdrawing or wanting to be alone more than usual. *

If anything came up for you as you completed this assessment that you would like to share, please do so below.