Pinpointing Your Pain

Client Full Name *

Date of Assessment *

Your Email Address *

Used so Dr. Nicole can follow up with you.

Session Number / Notes (optional)

List each pain point. Give it a title that truly captures your emotion, rate its intensity (1 = least painful, 10 = most painful), and select its category.

Categories: CGU = Childhood/Growing Up · FM = Family Matters · F = Friends · RR = Romantic Relationships · WCS = Work/College/Social · Y = Yourself

1 Pain Point #1

Pain Point Title

Rank (1–10)

Category

2 Pain Point #2

Pain Point Title

Rank (1–10)

Category

3 Pain Point #3

Pain Point Title

Rank (1–10)

Category

4 Pain Point #4

Pain Point Title

Rank (1–10)

Category

5 Pain Point #5

Pain Point Title

Rank (1–10)

Category

6 Pain Point #6

Pain Point Title

Rank (1–10)

Category

7 Pain Point #7

Pain Point Title

Rank (1–10)

Category

You may list fewer pain points — leave unused rows blank. We will explore each one in session.

You’ll be able to download or print your own copy after submitting.

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