Rate your current level of distress about the problem
Comfortable    Stressed   Very Stressed

How long has the problem been going on?
Less than One Month   More than a Year   Several Years

How long can you imagine living with the problem as it is now?
Much Longer - Years   A Year or Two   A Few Months

Are you mainly interested in (check all that apply):
Just getting information   
Discussing the problem and searching for solutions  
Continuing changes you have already begun  
Making Immediate changes  

Are you fearful of making necessary changes to address the problem?
Yes, extremely   Yes, somewhat   Yes, slightly

Are there complicating factors blocking the possibility of change (e.g. small children, financial hurtles, physical problems)
Yes, several   Yes, a few   No

If so, are you ready to discuss other changes within these boundaries that might offer other solutions?
No, I dont think so   Yes, but will it help?   Yes

Are you willing to spend the time and money on counseling?
No   Yes, but it seems expensive   Yes