Your Name *

First Name

Last Name

Counsellor's Name

First Name

Last Name

1. I've felt edgy or nervous *

0 - Not at all

1 - Only occasionally

2 - Sometimes

3 - Often

4 - Most or all of the time

2. I haven't felt like talking to anyone *

0 - Not at all

1 - Only occasionally

2 Sometimes

3 - Often

4 - Most or all of the time

3. I've felt able to cope when things go wrong *

4 - Not at all

3 - Only occasionally

2 - Sometimes

1 - Often

0 - Most or all of the time

4. I've thought of hurting myself *

0 - Not at all

1 - Only occasionally

2 - Sometimes

3 - Often

4 - Most or all of the time

5. There's been someone I felt able to ask for help *

4 - Not at all

3 - Only occasionally

2 - Sometimes

1 - Often

0 - Most or all of the time

6. My thoughts and feelings distressed me *

0 - Not at all

1 - Only occasionally

2 - Sometimes

3 - Often

4 - Most or all of the time

7. My problems have felt too much for me *

0 - Not at all

1 - Only occasionally

2 - Sometimes

3 - Often

4 - Most or all of the time

8. It's been hard to go to sleep or stay asleep *

0 - Not at all

1 - Only occasionally

2 - Sometimes

3 - Often

4 - Most of all of the time

9. I've felt unhappy *

0 - Not at all

1 - Only occasionally

2 - Sometimes

3 - Often

4 - Most or all of the time

10. I've done all the things I wanted to *

4 - Not at all

3 - Only occasionally

2 - Sometimes

1 - Often

0 - Most or all of the time