1) Do you feel like your world is collapsing on you?
☐ Yes
☐ No
2) Do you wonder how you got to this point?
☐ Yes
☐ No
3) Do you wonder how you are going to make it financially?
☐ Yes
☐ No
4) Are you getting all kinds of different advice from friends and family?
☐ Yes
☐ No
5) Do you feel like you are a black sheep in society?
☐ Yes
☐ No
6) Are you unable to concentrate at work or at all?
☐ Yes
☐ No
7) Do you ever feel that you should or should have worked harder to make the marriage work?
☐ Yes
☐ No
8) Do you find yourself on an emotional rollercoaster?
☐ Yes
☐ No
9) Do you have a plan to get back on your feet?
☐ Yes
☐ No
10) Do you wish you had someone to speak to; who knows what you are feeling and can help you find answers?
☐ Yes
☐ No
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