Facing Fears Form (Sample)
(Example: Specific Phobia: Driving)
Date: January 12th
Exposure Exercise (What fear am I facing?): driving in a residential area
Fear Rating:
1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 - 10
No Fear Moderate Fear Extreme Fear
Start: 6 End: 3
Length of Time of Exposure: 30 mins
What did I learn? I was scared at first. It did get easier as I kept driving. My
anxiety was less this time than yesterday when I did the exposure exercise.
(Example: Social anxiety)
Date: June 27th
Exposure Exercise (What fear am I facing?): Asking strangers questions____
(asked for directions to the post office).
Fear Rating:
1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 - 10
No Fear Moderate Fear Extreme Fear
Start: 8 End: 4
Length of Time of Exposure: 35 mins – asked 12 people during that time
What did I learn? My anxiety did drop and by the end I wasn’t that anxious.
Most people were pleasant and helpful – only one person was rude and did not
help – so I guess asking for help doesn’t necessarily annoy others.
© AnxietyBC
Facing Fears Form
Date: ______
Exposure Exercise (What fear am I facing?):
Fear Rating:
1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 - 10
No Fear Moderate Fear Extreme Fear
Start: End:
Length of Time of Exposure: ______
What did I learn?
Date: ______
Exposure Exercise (What fear am I facing?):
Fear Rating:
1 – 2 – 3 – 4 – 5 – 6 – 7 – 8 – 9 - 10
No Fear Moderate Fear Extreme Fear
Start: End:
Length of Time of Exposure: ______
What did I learn?
© AnxietyBC
