Anxiety Screener Survey

Welcome! This is a brief questionnaire intended to help determine whether or not the Anxiety 101 group offered through the Binghamton University Counseling Center would be a good fit for you. Please answer all the questions below. If your answers indicate that you may be a good fit, you will be contacted for follow-up. Thank you!

1. Name (first and last)

Name (first and last)

2. E-mail address

E-mail address

3. Phone number

Phone number

4. This group is for students who want to learn more about anxiety and how to cope with it in a healthy and effective manner. This will include learning about what anxiety is, how it affects our bodies and minds, how maladaptive anxiety is maintained, and how it can be positively coped with and managed in a variety of different ways. Does this sound like a group you would benefit from?

This group is for students who want to learn more about anxiety and how to cope with it in a healthy and effective manner. This will include learning about what anxiety is, how it affects our bodies and minds, how maladaptive anxiety is maintained, and how it can be positively coped with and managed in a variety of different ways. Does this sound like a group you would benefit from? Yes

5. Each group session will typically involve education provided by the group leaders AND discussion/interaction among the gorup members and leaders. What is your level of willingness to participate in brief discussions about topics the leaders describe? (Use the entire rating scale below to indicate your level of willingness; the labels are general guidelines,)

Not at all		A little			Somewhat willing			Really willing		Totally willing
*Each group session will typically involve education provided by the group leaders AND discussion/interaction among the gorup members and leaders. What is your level of willingness to participate in brief discussions about topics the leaders describe? (Use the entire rating scale below to indicate your level of willingness; the labels are general guidelines,) Not at all		A little			Somewhat willing			Really willing		Totally willing

6. Can you attend Thursday afternoons between 3 and 5 for a 90 minute group meeting?

Can you attend Thursday afternoons between 3 and 5 for a 90 minute group meeting? Yes; I can meet starting any time between 3 and 5 on Thursdays.

Yes; I can only meet between 3 and 4:30 on Thursdays.

Yes; I can only meet between 3:30 and 5 on Thursdays.

No; I cannot attend at that time.

7. Are you willing to commit to attending the group for 8 consecutive weeks? (This is important!)

Are you willing to commit to attending the group for 8 consecutive weeks? (This is important!) Yes

Anxiety Screener

Anxiety Group Questionnaire