Depression Screening

Depression Screening - CONFIDENTIAL

The Peacemaker Center
Client Full Name *

First Name Last Name
Gender: *

Male Female
Client Email Address *
example@example.com
Which therapist are you scheduled with? *

I do not have a therapist at The Peacemaker Center
Please check the appropriate responses below as it relates to the past two weeks:
I feel sad *

Never or Rarely Sometimes Often Almost All the Time
I feel like a failure *

Never or Rarely Sometimes Often Almost All the Time
I have lost interest in my work *

Never or Rarely Sometimes Often Almost All the Time
I do not look forward to the future *

Never or Rarely Sometimes Often Almost All the Time
I feel guilty *

Never or Rarely Sometimes Often Almost All the Time
I have lost interest in my hobbies *

Never or Rarely Sometimes Often Almost All the Time
I feel that others don't like me *

Never or Rarely Sometimes Often Almost All the Time
I am unhappy with myself *

Never or Rarely Sometimes Often Almost All the Time
I doubt my own judgment *

Never or Rarely Sometimes Often Almost All the Time
I am easily frustrated *

Never or Rarely Sometimes Often Almost All the Time
I wish I were dead *

Never or Rarely Sometimes Often Almost All the Time
I feel lonely *

Never or Rarely Sometimes Often Almost All the Time
I avoid being around other people *

Never or Rarely Sometimes Often Almost All the Time
My eating patterns have changed over the post month, such as overeating, or loss of appetite *

Never or Rarely Sometimes Often Almost All the Time
I have suicidal thoughts *

Never or Rarely Sometimes Often Almost All the Time
I deserve to be punished *

Never or Rarely Sometimes Often Almost All the Time
I have difficulty making decisions *

Never or Rarely Sometimes Often Almost All the Time
I feel worn out *

Never or Rarely Sometimes Often Almost All the Time
I feel emotionally shut down *

Never or Rarely Sometimes Often Almost All the Time
I feel worthless *

Never or Rarely Sometimes Often Almost All the Time
I am not interested in sex *

Never or Rarely Sometimes Often Almost All the Time
I feel hopeless *

Never or Rarely Sometimes Often Almost All the Time
I blame myself for other people's problems *

Never or Rarely Sometimes Often Almost All the Time
I feel spiritually dead *

Never or Rarely Sometimes Often Almost All the Time
I have difficulty paying attention *

Never or Rarely Sometimes Often Almost All the Time
SCREENING SCORE
Your responses are for screening purposes only. We would love the opportunity to discuss your results with you. Press press the Submit button below. If you are not currently a client please complete our Appointment Request form at www.thepeacemakercenter.org.

SCREENING RESULTS:

1-20 Not Depressed to Mild

20-30 Mild to Moderate

30 + Moderate to Severe
Should be Empty: