Young Persons Self Assessment

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Name
First Name
Last Name
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Email
example@example.com
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Please choose which issues are currently present. You can choose as many as you like and please be aware that we may not be able to address every single issue in one session.
Anxiety
Lack of confidence
Self Esteem
Stress
Motivation
Eating issues
Fears/Phobias
Relationships
Alcohol
Memory
Sleeping
OCD
Bullying
Drugs
Smoking
Sports Performance
School Performance
Exam stress
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Describe any other issues that are not listed?
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Pick the issue that you feel currently effects you the most in your life and describe the triggers.What is the trigger means, what is going on before to experience the issue, what are you thinking or is someone else triggering you?
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Over the last week how have you been experiencing the following:
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Only occassionally
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Often
Mots of the time
I have felt, tense, anxious, nervous
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I am feeling calmer and more relaxed
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I have felt I have had someone to turn to for support
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I believe and trust in myself more
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I have felt I can cope when things go wrong better
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I have had difficulty sleeping
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I have felt unhappy
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I feel I am good enough
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I have unwanted thoughts and feelings
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I feel I am loveable
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I have felt, tense, anxious, nervous
I am feeling calmer and more relaxed
I have felt I have had someone to turn to for support
I believe and trust in myself more
I have felt I can cope when things go wrong better
I have had difficulty sleeping
I have felt unhappy
I feel I am good enough
I have unwanted thoughts and feelings
I feel I am loveable
Not at all
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Only occassionally
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Sometimes
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Often
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Mots of the time
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Not at all
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Only occassionally
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Sometimes
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Often
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Mots of the time
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Not at all
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Only occassionally
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Sometimes
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Often
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Mots of the time
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Not at all
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Only occassionally
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Sometimes
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Often
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Mots of the time
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Not at all
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Only occassionally
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Sometimes
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Often
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Mots of the time
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Not at all
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Only occassionally
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Sometimes
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Often
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Mots of the time
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Not at all
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Only occassionally
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Sometimes
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Often
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Mots of the time
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Not at all
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Only occassionally
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Sometimes
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Often
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Mots of the time
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Not at all
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Only occassionally
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Sometimes
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Often
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Mots of the time
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Not at all
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Only occassionally
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Sometimes
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Often
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Mots of the time
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Describe the symptoms.A symptom is once you have been triggered what are you feeling, think about how your body feels for example you shake or feel sick?
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Describe the behaviour or habit. What is your habit or behaviour means how do you respond when you are triggered and feel a certain way for example do you shout at someone or hide away?
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If you were giving some advise to a best friend to help them with their issue, what would you say to them that you feel would help them?
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Think of a situation or feeling that occurs frequently that you would like to change?E.G. I get nervous when when i am about to sit a test, i feel like i am being judge, i don't feel like i belong.
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What are your biggest fears in relation to the issue?What do they stop you from doing?
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How does this issue affect you at home?
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How does this issue affect you at school and any other environments like sport or with friends?
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How long have you been dealing with issue/s and when did it first start. Can you remember what was going on around you?
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On a scale on 1 - 10, how much is the issue, challenge or illness affecting your life with 1 not at all and 10 affects everything you do.
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Feel great
Intense negative feeling
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On a scale on 1 - 10, how much would you like for the issue, challenge or illness to improve?1 is not motivated at all, 10 highly motivated and willing for change to happen.
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Not al All
Highly motivated
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On a scale of 1 - 10 answer the following question - I recognise and understand the limiting beliefs about the issue.On a scale on 0 - 10, 0 strongly disagree, 10 = Strongly agree
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Not al All
Highly motivated
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On a scale of 1 - 10 answer the following question - I feel confident about myselfOn a scale on 0 - 10, 0 strongly disagree, 10 = Strongly agree
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Not al All
Highly motivated
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On a scale of 1 - 10 answer the following question - I believe and trust in myselfOn a scale on 0 - 10, 0 strongly disagree, 10 = Strongly agree.
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Not al All
Highly motivated
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On a scale of 1 - 10 answer the following question - I feel good enoughOn a scale on 0 - 10, 0 strongly disagree, 10 = Strongly agree.
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Not al All
Highly motivated
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On a scale of 1 - 10 answer the following question - I accept that I am lovableOn a scale on 0 - 10, 0 strongly disagree, 10 = Strongly agree.
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Not al All
Highly motivated
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Now think about what you would like to happen instead. What will it look like? How would you feel? Think about what your life would be like if you did not have the issue/s. Be descriptive and imagine being the best version of you and how you would look, what you would be doing more of etc.
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When you are thinking about the situation you would like to change what questions do you have that, if you could get an answer, it would be priceless about overcoming you issue?e.g. Imagine your mind is like a giant computer and when you type a question in it to ask your brilliant genius mind the root cause and reason for your issue what would you like to ask for example Why do always feel anxious around other people?
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What do you believe you can do to change the situation?If you could wake up tomorrow without the issue, what would you be doing differently?
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What WOULD happen if you DID have what you want to feel and be?List 5 things of what would happen if you did have what you want for example What would happen if you had unstoppable confidence? 1. Feel happy 2. Speak to more people 3. Go out more 4. Sign up for new classes 5. go to new places etc....
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What WOULDN'T happen if you did have what you want to feel and be?Now list 5 things of what WOULDN'T happen if you did have eg confidence 1. My mum wouldn't keep checking on me 2. My friends wouldn't talk to me and ask if I am ok 3. my teachers wouldn't give me any attention and check on me etc....
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What WOULD happen if you didn't have what you want to feel and be?Now list 5 things of what WOULD happen if you DIDN'T have eg confidence 1. My mum checks on me all the time 2. My friends speak to me and worry about 3. My teachers always check on me and I get to go out of class. (If you can't think of all 5, make sure you come up with 3 answers.
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What WOULDN'T happen if you DIDN'T have what you want to feel and be?Now list 5 things of what WOULDN'T happen if you DIDN'T have eg confidence 1. I wouldn't go out much 2. My friends wouldn't ask me to go out because I don' speak much 3. My teachers wouldn't leave me to get on with my work and give me more because they think i am not capable
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How do you react when you make a mistake?
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What would you like to do in the future?Imagine money was no object and you could do anything you wanted to do, what would you love to do and be?
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What are your favorite subjects at school and why?
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What are your most challenging subjects at school and why?
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You are watching a movie with some friends, what do you notice most?Only select the 1 that is most important to you
What the characters look like and what they are wearing?
The music, sound track and the voices
Your own feelings, the emotion and the atmosphere
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When you think about what you'll be doing next weekend, youOnly select the 1 that is most important to you
Can picture yourself doing it
Want to chat about it with your friends
You feel excited already
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If you have an argument with your parents youOnly select the 1 that is most important to you
Look angry and take aggressive stance
Shout a lot
Can be quite physical
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Your favorite subjects at school areOnly select the 1 that is most important to you
Anything arty
Anything where there are discussions in class or anything musical
Anything physical like sport of dancing
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When you are feeling ill what concerns you mostOnly select the 1 that is most important to you
What you look like
What you sound like
What you feel like
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After a holiday with friends you enjoy mostOnly select the 1 that is most important to you
Looking at the photos
Chatting about it
Remembering how much fun it was and how it felt
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When you are thinking about spending time with friends what's important to youOnly select the 1 that is most important to you
What you will wear
Who you will be talking to
What you will feel like when yo are with them
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When you are on your mobile phone you spend more timeOnly select the 1 that is most important to you
Texting and looking at photos
Calling friends
Playing with Apps
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Please take a look at this short You tube clip of my mentor Marisa Peer. She explains wonderfully how the brain works in a very short 20 minute Ted talk.It is not essential to watch and i will be going over this with you but can be very helpful for you. https://www.youtube.com/watch?v=zCv-ZBy6_yU
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Young Persons Terms and conditions, Policy and Privacy guidelines

PLEASE READ AND SHARE WITH YOUR PARENTS ANYTHING YOU DO NOT UNDERSTAND

I am looking forward to working with you and before we work together please make yourself familiar with the guidelines of our work together.

What do I do?

I, Claire Linturn am a Rapid Transformation Therapist, Clinical Hypnotherapist. I own a private practise and one of my areas of expertise is working with children, young
people and their families to help people better understand how they think, feel and behave.

Our work together is a partnership and you will be required to follow my guidelines as we work through them. Should you choose not to your treatment may be compromised.

Confidentiality

Your sessions will be confidential, however I will ask if you would like to share the information with a parent/guardian or the teachers as this can be very helpful for you to overcome your issue and help them support you more fully.

As a professional I am legally bound to disclose any information if you are at risk of harm by a person or yourself including sexual abuse and self harming. This will be reported to your parent/guardian, doctor, external agency and if working within a school directly to the safeguarding officer who will follow their own procedures. This is not a definative list and I recommend this link if you require further understanding and speak with your parent for more understanding. It is also a wonderful resource to assit you for overcoming your challenges. https://youngminds.org.uk/about-us/

Personal Data

As an essential part of my work, I collect some of your personal information, for
example, your name, address, your school, and other details. I understand that you
share very personal and at times, highly sensitive information with me when I work with
you, and so I know, that it’s really important for that information to be kept very safe.

What Information do I collect?

This includes your name, home address, email address, telephone and other contact
numbers and school information.I collect this in a number of different ways. For
example, this data may be given to us directly online or over the telephone, or when
corresponding with me by letter. During our session I make notes in your words and you may request to see them.

How do I keep your information safe?

I take my data security responsibilities very seriously and follow the UK data protection rules and laws.

All our information is stored very safely and I have strict rules around the technical
systems I use, how it is accessed and by whom. I make sure that your personal
information is held in a place that is not accessible by the public, and I have rules to
guard against improper use and accidental loss of data.

Can I see the information about me that you keep?

I have written this privacy notice which describes the ways in which I collect, manage, process, store and share information about you as a result of you visiting my website or working with me. The privacy notice also provides you with information about how you can have control over the use of your data. You can find the policy on my website www.creativecoachingtherapy.co.uk/contact.

Under the General Data Protection Regulations (May 2018), you can ask to look at, change or delete personal information that we have on you. You can do this by sending an email to the creativecoaching@outlook.com.

What to expect during a session/s with Claire Linturn?

You may experience some abreactions (an abreaction is an emotional response), such a crying, laughing, coughing, yawning and everyone is different to how they respond. This is an important part of the process as it releases any negative responses you have been experiencing.

Change happens very differently for each person. During the session you will experience a change however for a new pattern of behaviour of feeling to change some people notice it over a period of time or they may realise later on they are doing something they would not have done before.

It really is very important you commit to listening to the recordings and any additional work provided.
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I confirm I have read and understood the Terms and conditions and Privacy guidelines provided by Claire Linturn
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I confirm I am committed to following the guidelines for working with Claire Linturn and understand that if I choose not to follow them the outcome of the treatment will be compromised and our work together may have to be discontinued.
YESNO
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I confirm I understand that my sessions are confidential and Claire Linturn is legally obliged to disclose any information if required to the parents and if I am at risk of harm from others or to myself.
YESNO
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Thank you for answering these questions to gain a great understanding about you. I am excited to be working with you and together we can overcome your challenges and unleash the potential i already know you have. Lets find it together and make life this exciting adventure that we have all been born to have.

You are already amazing, now its your turn to truly believe it!

'If you always do what you have always done, then you get what you always got'. What's exciting is that you can change it and make things happen.
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