Client Assessment
Clinician name
*
Client name
*
First Name
Last Name
Client Email
*
example@example.com
Symptom Scaling Questionnaire
Instructions: Select a number between 0 and 10 to describe each category.
How would you rate your _________________ on average these days?
Rating (0=none, 10=severe)
Sadness
00
01
02
03
04
05
06
07
08
09
10
Suicidal Thoughts
00
01
02
03
04
05
06
07
08
09
10
Anxiety
00
01
02
03
04
05
06
07
08
09
10
Frustration/Anger
00
01
02
03
04
05
06
07
08
09
10
(continued, different rating scale)
Rating (10=great, 0=poor)
Sleep
10
09
08
07
06
05
04
03
02
01
Interest/Pleasure in Life
10
09
08
07
06
05
04
03
02
01
Appetite
10
09
08
07
06
05
04
03
02
01
Motivation
10
09
08
07
06
05
04
03
02
01
Concentration
10
09
08
07
06
05
04
03
02
01
Energy Level
10
09
08
07
06
05
04
03
02
01
Overall Life Satisfaction
10
09
08
07
06
05
04
03
02
01
Work/School Satisfaction
10
09
08
07
06
05
04
03
02
01
Relationship With Friends
10
09
08
07
06
05
04
03
02
01
Relationships With Partner(s)
10
09
08
07
06
05
04
03
02
01
Relationship With Family
10
09
08
07
06
05
04
03
02
01
CAGE AID
Please select yes or no for each question.
Yes
No
In the last three months, have you felt you should cut down or stop drinking or using drugs?
In the last three months, has anyone annoyed you or gotten on your nerves by telling you to cut down or stop drinking or using drugs?
In the last three months, have you felt guilty or bad about how much you drink or use drugs?
In the last three months, have you been waking up wanting to have an alcoholic drink or use drugs?
DSM V Severity Measure for Depression
During the past SEVEN DAYS, I have:
0
days
1-3
days
4-6
days
7
days
Had little interest or pleasure in doing things
Felt down, depressed, or hopeless
Had trouble falling or staying asleep, or sleeping too much
Felt tired or had little energy
Had poor appetite or overeating
Felt bad about myself-or that I am a failure or have let myself or my family down
Had trouble concentrating on things(such as reading the newspaper or watching television)
Moved or spoken so slowly that other people could have noticed - Or the opposite - been so fidgety or restless that I have been moving around a lot more than usual
Had thoughts that I would be better off dead or of hurting myself in some way
[For clinician, do not modify]
Total/Partial Raw score
DSM V Severity Measure for Generalized Anxiety Disorder
During the past SEVEN DAYS, I have:
Never
Occasionally
Half of the time
Most of the time
All of the time
Felt moments of sudden terror, fear, or fright
Felt anxious, worried, or nervous
Had thoughts of bad things happening, such as family tragedy, illhealth, loss of a job, or accidents
Felt a racing heart, sweaty, trouble breathing, faint, or shaky
Felt tense muscles, felt on edge or restless, or had trouble relaxingor trouble sleeping
Avoided, or did not approach or enter, situations about which Iworry
Left situations early or participated only minimally due to worries
Spent lots of time making decisions, putting off making decisions, orpreparing for situations, due to worries
Sought reassurance from others due to worries
Needed help to cope with anxiety(ex. alcohol or medication, superstitious objects, or other people)
[For clinician, do not modify]
Total/Partial Raw score
[For clinician, do not modify]
Average Total Score
For Staff Use (leave blank) – Reviewed by Clinician
Clinician Name
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: