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This private form is for any young person in Newport under 19 years of age who wants to see a counsellor.

**Please do not complete on behalf of a young person**


This part of the survey uses a table of questions, 

11.11. The following questions are about how you have been feeling OVER THE LAST TWO WEEKS. Please read each question carefully. Think how often you have felt like that in the last week and then tick the box you think fits best. Required
Strongly Agree (3)Mostly Agree (2)Mostly Disagree (1)Strongly Disagree (0)Don't Know (0)
I feel unhappy or cry a lot
I feel less like talking to anyone
I feel angry or lash out at people
I feel nervous or panicky
I feel tired or struggle to sleep
I feel the way I behave will get me into serious trouble
It’s hard to stay friends or make new friends
I don't always like myself
My troubles make school life tough
My troubles make my home life tough