Check those that apply to you. It will take about ten minutes to complete.
- Category One
- __ I am sometimes unable to control my anger.
- __ I often act impulsively, and this causes me great difficulty at times.
- __ I am preoccupied with gambling, and I seem to have trouble controlling that behavior.
- Category Two
- __ Over the past year I have drunk more alcohol or taken more drugs to satisfy my needs.
- __ Over the past year I have tried but been unable to reduce the amount of alcohol, drugs, or cigarettes I use.
- __ Over the past year I have had to use increasing amounts of alcohol or drugs to get the feeling I want.
- Category Three
- __ For at least the past two weeks, I have found it difficult to get any pleasure from daily activities I used to enjoy.
- __ For at least the past two weeks,I have been thinking frequently about wanting to die.
- __ For at least the past two weeks, I have felt sad most of every day.
- Category Four
- __ I have an extreme fear of some object or situation, and I believe this fear is unreasonable.
- __ I am extremely afraid of some object or situation, and that fear interferes with my ability to function normally.
- __ I am extremely afraid of some object or situation, and when I am exposed to it, I experience panic.
- Category Five
- __ I am afraid to be around other people in certain situations, and I realize that my fears may be unreasonable or excessive.
- __ In certain social situations, I feel extremely anxious.
- __ I am highly fearful of one or more situations in which I need to interact with people.
- Category Six
- __ I regularly eat a lot and then vomit or use laxatives to prevent weight gain.
- __ I am preoccupied with my weight or body shape, and as a result I eat or exercise in ways that others find unusual.
- __ I am unwilling or unable to eat enough to maintain a healthy body weight.
- Category Seven
- __ I often find myself having disturbing recollections related to a traumatic event in my past.
- __ I often have disturbing dreams about a terrible experience I had in the past.
- __ I sometimes find myself reliving the horror of an experience in the past.
- Category Eight
- __ For at least the past six months, I have experienced worry and excessive nervousness I find difficult to control.
- __ For at least the past six months, I have been extremely anxious and worried about a number of different events and activities.
- __ For at least the past six months, I have felt unusually restless, fatigued, irritable, or tense.
- Category Nine
- __ Over the past year my mood has sometimes changed without any apparent reason.
- __ My mood shifts rapidly from depressed to elevated for no apparent reason.
- __ Over the past year my mood has shifted quickly more than once from depressed to highly elevated.
- Category Ten
- __ I repeat certain behaviors or thoughts a lot and I can't seem to stop doing so.
- __ Certain thoughts occur to me over and over again and cause me anxiety.
- __ I do certain things or think certain things over and over to calm myself or to prevent something terrible from happening.
- Category Eleven
- ___ I have trouble eating, sleeping, scattered thoughts, forgetfulness, extreme fatigue, sadness, longing.
- ___ I feel guilty, have regrets, and keep re-living events connected to the death of my loved one.
- ___ I have a limited support network, financial strain, physical limitations, and feel hopeless.
- Category Twelve
- ___ I have experienced, witnessed, or had vicarious exposure to an event which was unexpected or out of my control.
- ___ I experienced a physical or psychological threat to myself or my loved one’s safety.
- ___ As a result of the event(s), I experience intense fear, hopelessness, or horror.
- ___ The event or experience overwhelms my ability to cope with daily living activities.
- Category Thirteen
- ___ I have experienced physical, emotional, or sexual abuse.
- ___ I have a history or current issue with substance use/abuse.
- ___ I have experienced domestic violence in my lifetime.
- ___ I have a history of mental health issues, previous suicide attempts and hospitalizations.
- ___ I have experienced divorce or have a history of divorce in my family of origin.
- ___ I have been incarcerated or a loved one has been incarcerated in my lifetime.
Scoring: if you left all the statements blank, you don't need a therapist. If you checked one item in one or more categories, you might not need a therapist. If you are concerned, you might want to talk with one of us. If you marked two or three items in one or more categories, you would benefit from seeing a therapist.
There is no need for you to suffer unnecessarily. Click on the appointment heading for information about getting help.