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Are you a new client?
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Who is your therapist?
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Pace Lawson, LPC, LCDC
Melissa Lawson, LPC
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In the last month, how often have you been upset because of something that happened unexpectedly?
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0 - Never
1 - Almost Never
2 - Sometimes
3 - Fairly Often
4- Very Often
In the last month, how often have you felt that you were unable to control the important things in your life?
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0 - Never
1 - Almost Never
2 - Sometimes
3 - Fairly Often
4- Very Often
In the last month, how often have you felt nervous and “stressed”?
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0 - Never
1 - Almost Never
2 - Sometimes
3 - Fairly Often
4- Very Often
In the last month, how often have you felt confident about your ability to handle your personal problems?
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0 - Never
1 - Almost Never
2 - Sometimes
3 - Fairly Often
4- Very Often
In the last month, how often have you felt that things were going your way?
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0 - Never
1 - Almost Never
2 - Sometimes
3 - Fairly Often
4- Very Often
In the last month, how often have you found that you could not cope with all the things that you had to do?
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0 - Never
1 - Almost Never
2 - Sometimes
3 - Fairly Often
4- Very Often
In the last month, how often have you been able to control irritations in your life?
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0 - Never
1 - Almost Never
2 - Sometimes
3 - Fairly Often
4- Very Often
In the last month, how often have you felt that you were on top of things?
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0 - Never
1 - Almost Never
2 - Sometimes
3 - Fairly Often
4- Very Often
In the last month, how often have you been angered because of things that were outside of your control?
*
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0 - Never
1 - Almost Never
2 - Sometimes
3 - Fairly Often
4- Very Often
In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
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Please Select
0 - Never
1 - Almost Never
2 - Sometimes
3 - Fairly Often
4- Very Often
Continue
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things
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0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
Feeling down, depressed or hopeless
*
Please Select
0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
Trouble falling asleep, staying asleep, or sleeping too much
*
Please Select
0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
Feeling tired or having little energy
*
Please Select
0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
Poor appetite or overeating
*
Please Select
0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
Feeling bad about yourself - or that you're a failure or have let yourself or your family down
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Please Select
0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
Trouble concentrating on things, such as watching television or reading the newspaper
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Please Select
0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
Moving or speaking so slowly that other people could have noticed. Or, the opposite - being so fidgety or restless
*
Please Select
0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way
*
Please Select
0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
If you experienced any of the problems above, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Next
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Feeling nervous, anxious, or on edge
*
Please Select
0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
Not being able to stop or control worrying
*
Please Select
0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
Worrying too much about different things
*
Please Select
0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
Trouble relaxing
*
Please Select
0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
Being so restless that it's hard to sit still
*
Please Select
0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
Becoming easily annoyed or irritable
*
Please Select
0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
Feeling afraid as if something awful might happen
*
Please Select
0 - Not at all
1 - Several days
2 - Over half the days
3 - Nearly every day
If you experienced any of the problems above, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
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