Appendix - 2. One of the most important sources of information for the psychologist is
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2 Appendix - One of the most important sources of information for the psychologist is the experiences which individuals undergo. I request you to help me in my work by sparing your valuable time to answer some questions given below. All responses will be kept confidential. I thank you for your co-operation. Self Anchoring Ladder Scale In the following questions you are requested to evaluate yourself on a T to '1' scale. One indicates the minimum and 1 indicates the maximum level. Tick {-/) the number which you fmd appropriate to represent your thoughts about stress. Q. 1. In your opinion your life is to what extent stressful Q.. To what extent do you feel that you have coped with stressful situations successfully
3 Appendix - Assessment of Stress Source, Impact and Coping Style: 1. If you are asked to look into your life and record the experiences that have disturbed and distressed you most, which experiences would come immediately to your mind as the most powerful stresses in your life? Please write about it in details.. Is there any other notable experience sad or happy that you would like to record?. These experience must have affected you very strongly and probably influenced you in some lasting way. What do you think has been the impact of these experiences on you? 4. As an intelligent person you must have tried to handle distressing situation in the best possible manner. What did you do to reduce the stress and come out of the crises? 16
4 Appendix - LIFE EXPERIENCE SURVEY (LES) Listed below are a number of events which sometimes bring about change m the lives of those who experience them and which necessiate social readjustment. Please check only those events which you have experienced in the recent past. Be sure that all check marks are directly across from the items they correspond to. Also, for each item check below, please indicate the extent to which you viewed the event as having either a pleasant or unpleasant impact on your life at the time the event occurred. That is, indicate the type and extent of impact that the event had. A rating of - would indicate an extremely unpleasant impact. A rating of '' suggests no impact either pleasant or unpleasant. A rating of + would indicate an extremely pleasant impact. 16
5 s. No Item s ^ P <u u o ol W S U O i 1 c/ o c: J a. o Z f l l l l. p g u g I S c^-a I a ou Marriage Detention in jail or comparable institution Death of spouse Major change in sleeping habits (much more or much less sleep) Death of close family Members: a. mother b. father c. brother d. sister e. grandmother f grandfather g. other (specify) Major change in eating habits (much more much less food intake) Foreclosure on mortgage or loan -J Death of close friend Outstanding personal achievement -J Minor law violation (traffic tickets, disturbing peace etc.) -J Male: wife/girl friend's pregnancy Female pregnancy
6 1 Changed work situation (different work responsibilities major change in working conditions, working hours etc.) New Job Serious illness or injury of close family members a. father b. mother c. sister d. brother e. grandfather f grandmother g. spouse h. other (specify) Sexual difficulties Trouble with employer (in danger of losing job, being suspended demoted, etc.) - - -I 1 18 Trouble with in-law Major change in financial status (lot of better-off or lot worse-off) Major change in closeness of family members (increased or decreased closeness) 1 Gaining a new family member (through birth adoption, family member moving in etc.) I Change of residence I 165
7 Marital separation from mate (due to conflict) 4 Major change in church, mosque, temple activities (increased or decreased attendance) 5 Marital reconciliation with mate Minor change in number of arguments with spouse (a lot more or a lot less arguments) 7 Married Male; Change in wife's work outside the home (beginning work, closing work, changing to a new job etc.) 8 Married Female: Change in husband's work (loss of job, beginning new job, retirement, etc.) 9 Major change in usual type and/ or amount of recreation Borrowing more than $1, (buying home business etc.) 1 Borrowing less than $1, (buying car. TV, getting school loan, etc.) Being Fired from job I Male: wife/girl friend having abortion Female: having abortion - - -I 1 5 Major personal illness Major change in social activities e.g. -J parties movies, visiting (increased or decreased participation) 166
8 7 Major change in living conditions of - - family (building new home, remodelling, deterioration of home neighborhood etc) 8 Divorce Serious illness or injury or illness of - - close friend 4 Retirement from work Son or daughter leaving home (due - - to marriage, college etc) -1 4 Ending of formal schooling Separation from spouse (due to - - work, travel etc) 44 Engagement Breaking up with boy friend/girl - - friend 46 Leaving home for thefirsttime Reconciliation with boy friend/girl - - friend 48 other recent experience which have had an impact on your life list and rate - - Section : Student only 51 Beginning a new school experience - - at a higher academic level (college graduate school, professional school etc) 5 Changing to a new school at same - - academic level (undergraduate, graduate etc) 5 Academic probation
9 54 Being disn\issed from dormitory or other residence Failing an important exam Changing a major Failing a course Dropping a course Joining a Fratemity/sorority Financial problems concerning - - school (in danger of not having sufficient money to continue) 168
10 Appendix - PWB QUESTIONNAIRE: Given below are a number of questions regarding health, w^ll-being, attitudes and interest. We request you to answer them by encircling yes if the answer is true or mostly true of you and no if the answer is false r mostly false. There are no right or wrong answers. All the information given by you will be kept confidential. Please cooperate with us and answer frankly. THANK YOU 1 On the whole I would say my health is good Y^s No Compared to others of my age and background I am better of Yes No In the past I have received much support/ when I really needed it. Yes No 4 My life often seems empty. Yes No 5 I have recently been getting a feeling of tightness or pressure in my Yes No head. 6 I feel worthless.at times. Yes No 7 I have felt pleased about having accomplished something. Yes No 8 I have recently felt capable of making decisions about things. Yes No 9 Life is better now that I had expected it to be. Yes No 1 I have recently thought of the possibility that I may kill myself Yes No 11 In my case, getting what I want does not depend on luck. Yes No 1 I have recently been getting edgy and bad tempered. Yes No 169
11 1 I have recently felt that on the whole I am doing things well. Yes No 14 I have recently been feeling in need of a good tonic. Yes No 15 I feel all alone in the world. Yes No 16 I have recently been getting pains in my head. Yes No 17 I feel I am a person of worth, at least equal to others. Yes No 18 I have felt proud because someone complimented me on some Yes No achievement. 19 I have recently been able to enjoy my normal day to day activities. Yes No These are the best years of my life. Yes No 1 I have recently found that the idea of taking my own life kept coming Ves No to my head. What happens to me depend on me alone. Yes No I am happy/ satisfied with the support I have received. Yes No 4 I have recently felt constantly under strain. Yes No 5 I have recently felt perfectly well and in good health. Yes No 6 I have recently been satisfied with the way, have carried out my task. Yes No 7 (In case married), considering everything I would say, in marriage, I Ye: No am satisfied. 8 On the whole, I would say that my life is satisfactory at present. Yes No BIO-PATA Name: Qualification: Residence: Number of Family Members: Educational Status of Parents: Father: Age: Sex; Occupation: Rural / Urban Monthly Income: Mother: 17
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Marriage. Marital status continues to change. Marriage rate has declined since 1950 Birth rate has declined since 1950
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Wills & Estate Planning Information requested and/or things to consider for the drafting of your Last Will & Testament
ESTATE PLANNING WORKSHEET Wills & Estate Planning Information requested and/or things to consider for the drafting of your Last Will & Testament LEGAL NAME Date of Conference ADDRESS ZIP CODE TOWNSHIP
Family Counseling Center Children s Questionnaire (to age 10) For Parent/Guardian to Complete. Child s Name: DOB: Age:
Family Counseling Center Children s Questionnaire (to age 10) For Parent/Guardian to Complete Child s Name: DOB: Age: School: Grade: Race/Ethnic Origin: Religious Preference: Family Members and Other Persons
