Full Name: Email Address:

Over the last couple of weeks how often have you or has your loved one been affected by the following problems?

1. Feeling nervous, anxious, or on edge

YesNo

2. Not being able to stop or control worrying

YesNo

3. Worrying too much about different things

yesno

4. Trouble relaxing

yesno

5. Being restless, it is hard to sit still

yesno

6. Becoming easily annoyed or irritable

yesno

7. Feeling afraid, as if something awful might happen

yesno

If you answer yes to three or more questions, call Alchemy Consulting and we can help you find the right resources for your family.