Individual Pre-Counselling Assessment Form

This information is confidential to you. If you have a partner, it will not be shared with them unless you choose to do so.

First Name *

Last Name *

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things *Not at allSeveral daysMore than half the daysNearly every day

Feeling down, depressed, or hopeless *Not at allSeveral daysMore than half the daysNearly every day

Trouble falling or staying asleep, or sleeping too much *Not at allSeveral daysMore than half the daysNearly every day

Feeling tired or having little energy *Not at allSeveral daysMore than half the daysNearly every day

Poor appetite or overeating *Not at allSeveral daysMore than half the daysNearly every day

Feeling bad about yourself - or that you are a failure or have let yourself or your family down *Not at allSeveral daysMore than half the daysNearly every day

Trouble concentrating on things such as reading the newspaper or watching television *Not at allSeveral daysMore than half the daysNearly every day

Thoughts that you would be better off dead, or of hurting yourself *Not at allSeveral daysMore than half the daysNearly every day