Name:
    DoB:
    Email:

    Today's Date:

    What is the average number of hours of sleep per day that you had since last session?

    Instructions: Check the box to indicate how depressed, anxious, or angry, you've been feeling over the past week, including today. Please answer all items.

    Depression
    1. Sad or down in the dumps
    2. Discouraged or helpless
    3. Low self-esteem
    4. Worthless or inadequate
    5. Loss of pleasure of satisfaction in life.

    Suicidal Urges
    1. Do you have any suicidal thoughts?
    2. Would you like to end your life?

    Anxiety
    1. Anxious
    2. Frightened
    3. Worrying about things
    4. Tense or on edge
    5. Nervous

    Anger
    1. Frustrated
    2. Annoyed
    3. Resentful
    4. Angry
    5. Irritated

    Relationship Satisfaction
    Instructions: Select how satisfied or dissatisfied you feel in your closest personal relationship. Please answer all 5 items.

    1. Communication and openness
    2. Resolving conflicts and arguments
    3. Degree of affection and caring
    4. Intimacy and closeness
    5. Overall Satisfaction