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    If you wish to automatically receive a copy of this form insert your email address. You are advised to protect your privacy by creating a separate anonymous email account for this purpose which does not contain any identifying details. I suggest that my clients use their ID number as the email address, rather than their own name e.g. WU456YT@gmail.com

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    Pick a Date
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    Write briefly in each box:

    • What you did (brief description), one word that descripbes your mood, and rate the intensity of you mood on a scale of 0-100%
    • your sense of achievement for an activity (A0-10)
    • your sense of closeness to others (C0-10)
    • sense of enjoyment (E0-10).

    An activity may be sitting down, lying in bed, not only washing dishes, walking the dog etc.

    Example: Watching TV with son. Sad 60%, A0, C7, E4

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  • 18

    Dr Alesia Moulton-Perkins, CPsychol

    Online Psychology and Counselling Ltd

    To complete this form again go to:

    https://onlinepsychologyandcounselling.com/resources

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