Karlton
Terry & Team Workshops and Trainings
Life Stress Evaluation
Please complete
the following life stress evaluation form. It is important for Karlton Terry
to have a sense of the degree of stress in your life because this affects the
type of aproaches that are used in the workshop. It also helps to ensure that
the workshop matches your needs as closely as possible.
Name: _________________________________________________________________
Present occupation or profession: ____________________________________________
Rate the degree of stress in your occupation or profession from 1 (no stress)
to 10 (severe stress).
A rating of 5 is average stress: _____
Rate the degree of stress in you life from 1-10: _____
In the last ten years, how many of these years did you experience above-average stress? _____
How many years would you estimate that you had stress above 7? _____
The following checklist of events are usually considered highly distressing. Please check the items that have occurred to you regardless of how long ago. Your responses will be kept confidential.
_____ Divorce--How many? _____
_____ Acrimonious divorce
_____ Separation but no divorce
_____ Spontaneous abortion/miscarriage
_____ Stillbirth
_____ Death of close friend--Number: _____
_____ Death of close relative--Number: _____
_____ Serious illness in the family
_____ Serious personal illness
_____ Involved in a car accident
_____ Injured in a car accident
_____ Loss of income
_____ Fired from job
_____ Job stress
_____ Financial crisis
_____ Bankruptcy
_____ Sued (by someone else)
_____ Sued someone
_____ Relative sued (by someone else or sued someone)
_____ Won a lawsuit
_____ Lost a lawsuit
_____ House robbed but not present
_____ House robbed and present
_____ Robbed at gunpoint
_____ Significant object stolen
_____ Victim of domestic violence
_____ Physically abused
_____ Emotionally abused
_____ Sexually abused
_____ Raped
_____ Blackmailed by friend
_____ Blackmailed by employee
_____ Rejected by close friend or relative
_____ Abandoned by close friend or relative
_____ Emotional crises not mentioned in this list (describe below)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Signature: _________________________________________
Print Name: ________________________________________
Date: _____________________________________________
Thank you for your assistance.
Return this form with your deposit to:
Karlton Terry
303-832-1117
fax 303-832-2404
750 E 9th Ave #207
Denver, Colorado 80203
KTprenate2birth@gmail.com