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Name(Optional): School:
Age: Year level:
Choose UA if you ULTIMATELY AGREE, A if you AGREE and DA if you DISAGREE. A
space is also provided for you to answer the

Question: What is fear? U A D

A A
It is something that I don’t want to lose or have.
It is something that can affect my decisions and level of
determination.
It is something that is living inside my mind.
It is something that I don’t want to hear/see/touch/taste/feel.
questions in your own words(Optional).
Answer:

Question: What is your greatest U A D

fear? A A
Losing someone I love. (Family/Friends/Partner etc.)
Disappointing the people around me. (Not reaching their
expectations)
Imaginations, whispers and images inside my mind.
Kind of an animal/thing/food/place.

Answer:

Question: What are the things that you do U A D

when you are suffering from A A
anxiety/stress?
Making solutions for me to cope with the situation. (Doing something
to solve the problem)
Seeking attention. (Going out with friends/Opening my situation to
others/Telling it to the closest person I know etc.)
Just letting the time to pass and keeping it to myself hoping that one

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day it will be gone.

I’m avoiding to interact with it.
Answer:

Question: What are the common reasons of U A D

your anxiety/stress? A A
Problems that I’m encountering in my environment. (Someone hurt
me/Family Problem/Friendship over/Break-ups etc.)
Not being able to do the responsibilities that I should do. (School
works/Household Chores/Settled Plans etc.)
Having verbal/non-verbal discouragements and because of it I’m
always imagining myself as a failure.
Private Reasons (Experiences/Memories)

Answer:

On this portion write anything you want to say. You have the freedom to open-up

anything (Message for someone/anything under the sun). (Optional)

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Define Yourself:

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