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Full Name
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Phone
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Email
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How often do you feel overwhelmed by worry or fear?
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Never
Occasionally
Frequently
Almost Always
Do you experience physical symptoms like headaches, stomach aches, chest pains, or muscle tension due to stress?
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Never
Rarely
Often
All the time
How often do you have trouble sleeping due to anxious thoughts?
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Never
Occasionally
Often
All the time
Do you feel like anxiety interferes with your ability to complete daily tasks?
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Never
Occasionally
Often
Always
How often do you turn to God in prayer or Scripture (faith-based practices) to manage your anxiety?
Never
Occasionally
Often
Always
Do you find it difficult to control racing thoughts or intrusive worries?
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Not at all
Occasionally
Often
Always
How comfortable are you opening up about your struggles with anxiety to close friends or family?
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Very Comfortable
Somewhat Comfortable
Rarely Comfortable
Not at all comfortable