Self Assessment SB

Complete the whole Form Before You Start Your Session

Your Surname *

Which Counsellor

Questionnaire (part 1) PHQ-9

Q1 – Have you found little pleasure or interest in doing things? *

Q2 – Have you found yourself feeling down, depressed or hopeless? *

Q3 -Have you had trouble falling or staying asleep, or sleeping too much? *

Q4 -How often have you been bothered by feeling tired or having little energy? *

Q5 – How often have you been bothered by poor appetite or overeating? *

Q6 -How often have you been bothered by feeling bad about yourself, or that you are a failure, or have let yourself or your family down? *

Q7 – How often have you been bothered by trouble concentrating on things, such as reading the newspaper or watching television? *

Q8 – How often have you been bothered by moving or speaking so slowly that other people could have noticed, or the opposite – being so fidgety or restless that you have been moving around a lot more than usual? *

Q9 – Thoughts that you would be better off dead, or of hurting yourself in some way? *

Questionnaire (part 2) GAD-7

Q1 – How often have you been bothered about feeling nervous, anxious or on edge? *

Q2 – How often have you been bothered by not being able to stop or control worrying? *

Q3 – How often have you been bothered by worrying too much about different things? *

Q4 – How often have you been bothered by having trouble relaxing? *

Q5 – How often have you been bothered by being so restless that it is hard to sit still? *

Q6 – How often have you been bothered by becoming easily annoyed or irritable? *

Q7 – How often have you been bothered by feeling afraid as if something awful might happen? *

Data Protection Statement

Paragraph

Signature

Clear

Complete the whole Form Before You Start Your Session

Questionnaire (part 1) PHQ-9

Questionnaire (part 2) GAD-7

Data Protection Statement

Contact Form