Pitts Davis Counseling Services

Name *

First

Last

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

Sad or down in the dumps *

Discouraged or hopeless *

Low self-esteem, inferiority, or worthlessness *

Loss of motivation to do things *

Loss of pleasure or satisfaction in life *

Check the box to indicate how you've been feeling over the past week, including today. Please answer all the items.

Have you had any suicidal thoughts? *

Would you like to end your life? *

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

Anxious *

Frightened *

Worrying about things *

Tense or on edge *

Nervous *

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

Frustrated *

Annoyed *

Resentful *

Angry *

Irritated *

Check the box to show how satisfied or dissatisfied you feel in your closest personal relationship.

Communication and openness *

Resolving conflicts and arguments *

Degree of affection and caring *

Intimacy and closeness *

Overall satisfaction *

Date *