Name *
Name
Over The Last 2 Weeks (New Clients), or Since Your Last Session, Have You Often Been Bothered By:
Little Interest or Pleasure In Doing Things? *
Feeling Down, Depressed, or Hopeless? *
In Your Life, Have You Ever Had Any Experience That Was So Frightening, Horrible, or Upsetting, Etc., That In The Past Month (New Clients), or Since Your Last Session, You:
Have Had Nightmares About It or Thought About It Even When You Did Not Want To? *
Tried Hard Not To Think About It or Went Out Of Your Way To Avoid Situations That Reminded You Of It? *
Were Constantly On Guard, Watchful, or Easily Startled? *
Felt Numb or Detached From Others, Activities, or Your Surroundings? *
Over The Past 2 Weeks (New Clients), or Since Your Last Session, How Often Have You Been Bothered By The Following Problems?
Feeling Nervous, Anxious, or On Edge *
Not Being Able To Stop or Control Your Worrying *
Feeling Restless, Unable To Sit Still, or Difficulty Concentrating *
Becoming Easily Annoyed or Irritable *
Having Anger Outbursts *
If You Checked Off Any Problems, How Difficult Have These Problems Made It For You To Do Your Work, Take Care Of Things At Home, or Get Along With Others? *
In The Past 2 Weeks (New Clients), or Since Your Last Session, Have You Had Thoughts You Would Be Better Off Dead or Hurting Yourself In Some Way? *
Today's Date *
Today's Date