01732 808 626 info@thinkcbt.com

01732 808 626 info@thinkcbt.com

01732 808 626 info@thinkcbt.com

Fear Questionnaire (FQ)
You can respond anonymously, and no data will be retained from this assessment. If you choose to include your initials and an email address, your results will be automatically sent to the email address provided. Please check that the email address has been entered correctly before submitting this form. All client information is managed on a strictly confidential basis. Please Note: Whilst every effort is made to ensure that our system is securely encrypted, email is not a completely secure means of communication. Think CBT does not accept liability for loss or theft of personal data where any individual chooses to transmit or receive information via email.
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Fear Questionnaire (FQ)

Choose a number from the scale below to show how much you would avoid each of the situations listed below because of fear or other unpleasant feelings.

0 1 2 3 4 5 6 7 8
Would not avoid it                Slightly avoid it                Definitely avoid it                   Markedly avoid it                     Always avoid it

Main phobia you want treated, please describe...
1. Main Phobia you want treated - avoidance levels
2. Injections or minor surgery
3. Eating or drinking with other people
4. Hospitals
5. Travelling alone or by bus
6. Walking alone in busy streets
7. Being watched or stared at
8. Going into crowded shops
9. Talking to people in authority
10. Sight of blood
11. Being criticized
12.Going alone far from home
13, Thought of injury or illness
14. Speaking or acting to an audience
15. Large open spaces
16. Going to the dentist
17. Other Situations

Please describe the situation/s

18. How would you rate the scale of your phobic symptons on the scale below?


0 1 2 3 4 5 6 7 8
no phobias present                slightly disturbing/not really disabling                definitely disturbing/disabling                   markedly disturbing/disabling                     very severely disturbing/disabling

Now choose a number from the scale below to show how much you are troubled by each problem listed.


0 1 2 3 4 5 6 7 8
hardly at all                slightly troublesome                definitely troublesome                   markedly troublesome                     very severely troublesome

19. Feeling miserable or depressed
20. Feeling irritable or angry
22. Upsetting thoughts coming into your head
23. Feeling you or your surroundings are strange or unreal
Other Feelings (please describe)
24. How much do these other feelings trouble you?