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Individual Therapy
Relationship Coaching
Wellness Courses
Pricing
Name
*
First Name
Last 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?
*
Yes
No
Feeling Down, Depressed, or Hopeless?
*
Yes
No
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?
*
Yes
No
Tried Hard Not To Think About It or Went Out Of Your Way To Avoid Situations That Reminded You Of It?
*
Yes
No
Were Constantly On Guard, Watchful, or Easily Startled?
*
Yes
No
Felt Numb or Detached From Others, Activities, or Your Surroundings?
*
Yes
No
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 At All
1-2 Days
3-5 Days
Every Day
Not Being Able To Stop or Control Your Worrying
*
Not At All
1-2 Days
3-5 Days
Every Day
Feeling Restless, Unable To Sit Still, or Difficulty Concentrating
*
Not At All
1-2 Days
3-5 Days
Every Day
Becoming Easily Annoyed or Irritable
*
Not At All
1-2 Days
3-5 Days
Every Day
Having Anger Outbursts
*
Not At All
1-2 Days
3-5 Days
Every Day
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?
*
Not Difficult At All
Somewhat Difficult
Very Difficult
Extremely Difficult
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?
*
Yes
No
Today's Date
*
MM
DD
YYYY
Thank you!
