Call us today at  (704)-896-7776 to schedule your appointment

or complete the contact form below and we’ll get back to you.

New Client Paperwork:

New Client Paperwork – Adolescent

New Client Paperwork – Adult

View Larger Map

 Southlake Counseling


903 Northeast Drive,
Suite 201,
Davidson, NC 28036




Statement Less True More True
  1.   I am not satisfied with my height and I often wish I were taller or shorter.
  1. I am not satisfied with my height and I often wish I were taller or shorter.
  1. My ideal skin complexion (tone, appearance) is quite different from my own skin.
  1. I get nervous if people see be before I have finished fixing myself up and I would typically try to hide myself.
  1. I am uncomfortable in many types of more revealing or form fitting clothes, and I often try to hide myself in my clothes.
  1. I am sure that I have a physical flaw which is highly noticeable to other people.
  1. My ideal weight is very different from my current weight.
  1. When I look at myself, the first things I see are several flaws, rather than several attractive characteristics.
  1. I commonly compare myself to attractive people I see in movies, in magazines, in person, or on television.
  1. I frequently cringe or become upset when I look at photos or videos of myself.
  1. I commonly have thoughts like, "I really hate what I see when i look at myself. I notice body parts sticking out, my unattractive skin or hair, or features that are too large or oddly shaped".
  1. I can't stand to look at myself after I have eaten a full meal.
  1. I became highly self conscious when my partner touches a body area that i do not like.
  1. I work hard to make sure that nobody sees me undressed or in minimal clothing such as a bathing suit. If they have to, I make sure that the lights are on low or are off or I am covered up.
  1. I try not to go out if my hair is not fixed just right, my clothes are not perfectly put together or (for women) my makeup is not exactly right.
  1. On a typical day, I have at least five different thoughts about how unattractive my looks are.
  1. I often feel upset about my body shape when I look in the mirror or try clothes on.
  1. It is typical for me to think that people will not love me or that they will love me less because of how I look.
  1. I frequently think, "My life would be much better if I were more attractive."
  1. When I look at myself, I tend to stare at one feature that I think is large, small, or distorted.
  1. I feel uncomfortable around people I think are attractive because I believe they must think I am unattractive. Other people observing me with an attractive person would notice the difference between me and the nice-looking person.
  1. I do not believe that I can wear stylish or fashionable clothes.
  1. I am constantly telling myself that I need to change something about my looks.
  1. I feel obvious of people who have had makeovers or plastic surgery because I would like to significantly change how I look.
  1. Others probably judge me negatively, think less of me, or do not liek me because If how I look.
  1. I avoid having my picture taken since I do not want to be captured on film forever looking the way I do.
  1. My body needs to be more firm, slim, toned, or tight.
  1. I feel highly uncomfortable when others are looking at me because I am sure they are noticing my physical flaws.
  1. If someone give me a compliment about my physical appearance, I typically think that they are just saying it to be nice, but that it is not really true.
  1. I am sure that I am significantly less physically appealing than other people.

Your Total: