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

Although this form is completed over a secure link, please don't put your name or any identifying details. This is to protect your privacy

If you are completing this on your mobile phone, keep the form open in the background during the day, and when you get to the end of the day and have finished it, click submit.

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

Dr Alesia Moulton-Perkins, CPsychol

Online Psychology and Counselling Ltd

To complete this form again go to:

https://onlinepsychologyandcounselling.com/resources