Name
*
First Name
Last Name
Date
-
Year
-
Month
Day
Date
Neurofeedback Provider
*
Tyrrell Baker, Christine
Baker, Kelly
Gunther, Tiffany
Over the last 2 weeks, how often have you been bothered by the following problems?
*
Not at all
Several Days
More than half the days
Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so figety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself
Over the last 2 weeks, how often have you been bothered by the following problems?
*
Not at all
Several Days
More than half the days
Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
GSE
*
Not at all true
Hardly true
Moderately true
Exactly true
1. I can always manage to solve difficult problems
if I try hard enough.
2. If someone opposes me, I can find the ways and
means to get what I want
3.It is easy for me to stick to my aims and accomplish my goals.
4.I am confident that I could deal efficiently with unexpected events.
5. Thanks to my resourcefulness, I know how to handle unforeseen situations.
6.I can solve most problems if I invest the necessary effort.
7. I can remain calm when facing difficulties because I can rely on my coping abilities.
8. When I am confronted with a problem, I can usually find several solutions.
9. If I am in trouble, I can usually think of a solution.
10. I can usually handle whatever comes my way
CSE When things aren't going well for you, or when you're having problems, how confident or certain are you that you can do the following:
*
Cannot do at all
0
1
2
3
4
Moderately certain can do
5
6
7
8
9
Certain can do
10
1.Keep from getting down in the dumps.
2.Talk positively to myself
3.Sort out what can be changed, and what cannot be changed.
4.Get emotional support from friends and family.
5.Find solutions to your most difficult problems
6.Break an upsetting problem into smaller parts
7.Leave options open when things get stressful
8. Make a plan of action and follow it when confronted with a problem
9. Develop new hobbies or recreations.
10.Take your mind off unpleasant thoughts.
11.Look for something good in a negative situation
12.Keep from feeling sad
13.See things from the other person's point of view during a heated argument.
14.Try other solutions to your problems if your first solutions don't work.
15.Stop yourself from being upset by unpleasant thoughts.
16.Make new friends
17. Get friends to help you with things you need.
18. Do something positive for yourself when you are feeling discouraged.
19.Make unpleasant thoughts go away.
20.Think about one part of a problem at a time.
21.Visualize a pleasant thought or activity.
22. Keep yourself from feeling lonely.
23.Pray or meditate
24.Get emotional support from community organizations or resources.
25.Stand your ground and fight for what you want.
26.Resist the impulse to act hastily under pressure
BDES. One of the things that stress does is make us feel disconnected. How much has each of these experiences happened to you over the LAST 7 DAYS?
*
Not at all
Once or twice
Almost everyday
About once a day
More than once a day
1.I find myself staring into space and thinking of nothing.
2. People, objects, or the world around me seem strange or unreal.
3. I find that I did things that I do not remember doing.
4. When I am alone, I talk to myself out loud.
5. I feel as though I were looking at the world through a fog so that people and things seem far away or unclear.
6.I am able to ignore pain.
7. I act so differently from one situation to another that it is almost as if I were two different people.
8. I can do things very easily that would usually be hard for me.
LD: How often do you experience the following difficulties:
*
Never
0
1
Not Often
2
3
4
Sometimes
5
6
Often
7
8
9
All the time
10
1. I have trouble controlling my anger/ irritability.
2.I feel stuck, unable to change.
3. I feel panicky and anxious in my body.
4. I feel helpless.
5.I feel on edge, hypervigilant.
6.I feel scattered in my mind and can't focus.
7.I find myself overreacting emotionally.
8. I procrastinate.
9. I numb, distract, and/or avoid things.
10.I ruminate about my problems.
11.I can't make decisions.
12.I am stressed.
13.I feel like hiding rather than reaching out.
14. I am overwhelmed.
15.I am tired in my body.
16.I have symptoms of digestive problems.
17. I have pain in my body.
Submit
PHQ-9 Score 0-4 Minimal 5-9 Mild 10-14 Moderate 15-19 Moderately-Severe 20+ Severe
GAD-7 Score 0-5 Minimal 6-10 Mild 11-15 Moderate 16-21 Severe
GSE score
Calculation
CSE score
LD score
BDES total score
Should be Empty: