Wellness Tracking form

This form is designed to help you reflect on your emotional well-being and identify areas you’d like to focus on in therapy.

Your responses are confidential and will only be used to support your personal growth.

Emotional Well-being

On a scale of 1–5, how often do you experience the following:

(1 = Never ,5 = Always)

I feel calm and in control of my emotions. *

I feel anxious or stressed. *

I have difficulty sleeping or relaxing. *

I feel positive about myself and my future. *

I experience mood swings or emotional highs/lows. *

Relationships & Communication

I can express my feelings openly and clearly. *

I feel supported by the people around me. *

I often experience conflicts or misunderstandings. *

Self-Care & Lifestyle

I make time to rest and recharge. *

I eat well and maintain a healthy routine. *

I engage in activities that bring me joy. *

I take care of my emotional and physical health. *

Personal Reflection

What are the main challenges or concerns you’d like to work on?

What goals would you like to achieve through counselling?

What strengths or positive qualities do you recognize in yourself?

Progress & Awareness

I understand my emotions better than before. *

Yes

Somewhat

I’ve noticed positive changes in myself. *

Yes

Somewhat

I feel more confident in handling life’s challenges. *

Yes

Somewhat

Thank you for taking the time to reflect.

Your self-awareness is the first step toward healing and growth.

Together, we’ll continue nurturing your journey toward balance and peace.

Mumbai, India

When You Can Reach Us

Mon - Sat 10:00 AM - 6:00 PM
Sunday Closed

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