Enrollment

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Approximately how many times per week do you feel anxious (have anxiety symptoms)?

Indicate the approximate number of hours on a typical day you are actively troubled by anxiety (either thinking about it, worrying, frightened, etc.) Please indicate a specific number even if it is just an estimate.

So that we can have a sense of where you might need the most help and a way to measure progress, please check the boxes below that apply to you. Please be sure to indicate the degree to which your happiness and/or productivity are impeded by marking the one to ten scales placed after each item you have checked (0 being least and 10 being most).

I have had one or more experiences of suddenly feeling very fearful with symptoms such as shortness of breath, palpitations, chest pain or discomfort, choking or smothering sensations, with fear of going crazy, losing control, a sense of impending doom, or perhaps even dying.
0 1 2 3 4 5 6 7 8 9 10

To keep from feeling afraid, perhaps going out of control, I tend to avoid certain situations such as: (if applies, please list)

I experience irrational fear and discomfort only when I am anticipating or actually faced with a specific item or situation (e.g. flying, spiders, heights, etc.) List up to four of the most debilitating things:

I tend to worry excessively and become very distressed about the same negative thoughts, images or impulses, and have trouble dismissing them. At least some relief is gained when I perform certain behaviors or rituals to feel less tense and troubled.
0 1 2 3 4 5 6 7 8 9 10

I have a strong unreasonable fear of one or more social or performance situations when I meet new people and/or might be judged. I fear acting in a way that might be humiliating or embarrassing to me.
0 1 2 3 4 5 6 7 8 9 10

Ever since I suffered a traumatic/greatly stressful event, I've been troubled with some of the following (Please list below): Disturbing memories, avoidances, sleep problems, irritability, trouble concentrating, jumpiness, flashbacks, loss of interest in the future, feeling “on guard”, unable to function some days, depressed, guilty.

I am generally uncomfortable or anxious much of the time, even though I don't worry about or fear having a panic attack or being embarrassed. I am unable to control the sense of apprehension I feel about a number of things.
0 1 2 3 4 5 6 7 8 9 10

List below medications you are currently taking and the usual dosage per day, please include: Medications Dosage How Often Why Prescribed

In general, how satisfying do you find the way you're spending your life these days? Which of the following would you call it?
0 1 2 3 4 5 6 7 8 9 10

Please indicate how depressed you feel at this time in your life.
0 1 2 3 4 5 6 7 8 9 10

Choose the number below which best describes the overall level of happiness, everything considered, of your present marriage, or primary relationship. (If you are not currently married or in a relationship, just skip this question)
0 1 2 3 4 5 6 7 8 9 10

Please indicate how much control of your life you now feel. (Choose a number)
0 1 2 3 4 5 6 7 8 9 10

If you are currently taking medications for your anxiety condition, please indicate how helpful it (they) has (have) been in proving relief from your distress. (Choose a number)
0 - No Relief at all 1 2 3 4 5 6 7 8 9 10 - Complete Relief

Please give a brief description on your anxiety condition now. Depression is also of interest.

Highest level of schooling completed?

Please tell us how you heard of the CHAANGE Program, and what convinced you to enroll. What was it in the free information kit and/or web page that helped?

Do you have children living at home? If yes please list their ages.

Have you ever seen a psychologist, psychiatrist or other professional or counselor for help for your anxiety condition?

If you are currently seeing a therapist, please include their name, degree and complete address. Indicate below if, as a courtesy, we may send information about the CHAANGE Program and that you have enrolled. Please provide Therapist's name, Address & Zip:

May we send info to your therapist about the CHAANGE Program?
Yes No

When did you last have a “thorough” physical examination?

What were the main findings of your most recent physical?

REQUEST TO USE INFORMATION FOR RESEARCH PURPOSES/INFORMED CONSENT AGREEMENT

It is very helpful for us to be able to use certain information you provide to us for a variety of research and study purposes. The type of information we use are answers to questions such as your self-rating of your anxiety symptoms on the pre-, mid-, and post-program evaluations. In accordance with ethical standards, we are required to inform you of the following, and obtain your informed consent prior to using any of the information you supply to us.

WE WILL NEVER USE OR RELEASE YOUR NAME OR OTHER IDENTITY INFORMATION EXCEPT FOR THE RESEARCHER TO WRITE YOU TO REQUEST WRITTEN PERMISSION AS IS SOMETIMES REQUIRED.

You are free to either participate or to decline to participate, or you may change your mind at any time by notifying us in writing. There is no foreseen effect of choosing either to participate or not to participate. There are no known risks or adverse effects if you choose to participate since the materials you will be filling out would be filled out in the normal course of your program participation. The benefits of participation would be to add your own experience to the knowledge base of anxiety research and treatment, information we can use to help others. If you have any questions at all concerning this matter, please ask us for further information.

Please indicate your decision below.
I agree to allow information I supply to be used I decline. Do not use any information I supply you

Remember, you can see a CHAANGE affiliated professional at their office, or take the strictly in-home arrangement, or receive the materials in-home and have regularly scheduled telephone consultations. Call us at CHAANGE with any questions. If you will be seeing a CHAANGE affiliated therapist, you can order the CHAANGE treatment materials directly from them.

CHAANGE Program Pricing Options

CHAANGE Program (CD's) $349 Full 16 Week Program

CHAANGE Program (Digital Download) $299 Full 16 Week Program

Payment Method:

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Expiration:
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

CVV(II):

The card security code (CVV) is a unique three or four digit number, separate from your credit card number.

Visa/MasterCard/Discover
Your card security code for your MasterCard, Visa or Discover card is a three-digit number on the back of your credit card, immediately following your main card number.

American Express
The card security code for your American Express card is a four-digit number located on the front of your credit card, to the right or left above your main credit card number.