Tidwell Consulting & Assoc.
PRE-ASSESSMENT QUESTIONNAIRE
TO APPLY FOR THE FACE PROGRAM YOU MUST COMPLETE THE ENTIRE ASSESSMENT - ANSWERING ALL QUESTIONS.
We ask that you be completely honest when answering these questions so The FACE Program will know where you fit in terms of services and resources. Your candidness will allow us to provide accurate resources to you. We are assessing your ability or inability to manage and cope with personal stressors in your life. Our program need to determine the level of these stressors which may contribute to being unable to stay focused in regard to paying bills and caring for your family in the best ways possible.
What type of assistance do you find yourself in need of most often? ____________________________________________________
Are you currently involved with any type of court proceedings? Yes or No If yes, please explain. ____________________________________________________________________________________________________________________________________________________________
Do you find yourself eating emotionally: eating unhealthy foods or eating when you’re not hungry, as a response to stress or difficult feelings?
No, I eat a healthy diet, and
only eat when hungry.
I admit I've binged on
occasion, but it's not a regular occurrence.
Yes, I have to admit that my
diet is pretty unhealthy.
Do you find yourself sweating excessively when you're not exercising?
No.
Sometimes, when I'm
particularly stressed, but not often.
Yes, it happens fairly
regularly.
Do you ever have trouble sleeping?
Rarely or never.
Sometimes I'll have trouble
falling asleep, staying asleep, or getting quality sleep.
Yes, I often have trouble with
sleep quality or with falling and staying asleep.
Do you suffer from burnout, anxiety disorders or depression?
No.
I don’t know.
Yes.
To identify your true sources of stress, look closely at your habits, attitude, and excuses:
Do you explain away stress as temporary (“I just have a million things going on right
now”) even though you can’t remember the last time you took a breather?
Do you define stress as an integral part of your work or home life (“Things are always
crazy around here”) or as a part of your personality (“I have a lot of nervous energy,
that’s all”).
Do you blame your stress on other people or outside events, or view it as entirely normal
and unexceptional?
Check all that apply to your ways of managing your stress.
|
Smoking Have a drink to relax Skipping meals / over eating Zoning out for hours in front of the TV or computer Withdrawing from friends, family, and activities
Have you noticed increased medical problems? |
Using pills or drugs to relax Sleeping too much Procrastinating Filling up every minute of the day to avoid facing problems Taking out your stress on others |
Increase in BP
Increase in headaches
Blurred vision
Hearing loss
Irritable bowels / nausea
Skipping menstrual cycles
Do you find yourself wasting / spending bill money and then borrowing from family & friends to pay those bills?
Yes
No
Have you ever thought your family or children would be better off without you?
Yes
No
If yes, explain ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
The FACE Foundation and Tidwell Consulting & Associates would like to thank you for your honesty in completing this pre-assessment. This will allow us to better service you as well as determine whether you would benefit from The FACE Program.
For more information or questions, please contact Ms. Doreen Washington, Executive Director, The FACE Foundation at facefound@gmail.com or directly regarding your assessment results, Ms. Stacy Tidwell of Tidwell Consulting & Associates at salt701@msn.com.
Submit