Pitts Davis Counseling Services

Name *

First

Last

DEPRESSION

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 *

SUICIDAL URGES

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? *

ANXIETY

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 *

ANGER

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 *

POSITIVE FEELINGS

Please note that in this section, checking Not at all means that you have no positive feelings and checking Extremely means that you have strong positive feelings.

I feel worthwhile. *

I feel close to people *

People support and care about me. *

I enjoy life. *

I often laugh and smile. *

I feel motivated to do things. *

I feel productive. *

I feel hopeful. *

I feel peaceful. *

My life has a deeper meaning. *

Date *