Depression Screening

Depression Screening

CONFIDENTIAL
Client Full Name*

First NameLast Name
Gender:*

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

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

Never or RarelySometimesOftenAlmost All the Time
I feel like a failure*

Never or RarelySometimesOftenAlmost All the Time
I have lost interest in my work*

Never or RarelySometimesOftenAlmost All the Time
I do not look forward to the future*

Never or RarelySometimesOftenAlmost All the Time
I feel guilty*

Never or RarelySometimesOftenAlmost All the Time
I have lost interest in my hobbies*

Never or RarelySometimesOftenAlmost All the Time
I feel that others don't like me*

Never or RarelySometimesOftenAlmost All the Time
I am unhappy with myself*

Never or RarelySometimesOftenAlmost All the Time
I doubt my own judgment*

Never or RarelySometimesOftenAlmost All the Time
I am easily frustrated*

Never or RarelySometimesOftenAlmost All the Time
I wish I were dead*

Never or RarelySometimesOftenAlmost All the Time
I feel lonely*

Never or RarelySometimesOftenAlmost All the Time
I avoid being around other people*

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

Never or RarelySometimesOftenAlmost All the Time
I have suicidal thoughts*

Never or RarelySometimesOftenAlmost All the Time
I deserve to be punished*

Never or RarelySometimesOftenAlmost All the Time
I have difficulty making decisions*

Never or RarelySometimesOftenAlmost All the Time
I feel worn out*

Never or RarelySometimesOftenAlmost All the Time
I feel emotionally shut down*

Never or RarelySometimesOftenAlmost All the Time
I feel worthless*

Never or RarelySometimesOftenAlmost All the Time
I am not interested in sex*

Never or RarelySometimesOftenAlmost All the Time
I feel hopeless*

Never or RarelySometimesOftenAlmost All the Time
I blame myself for other people's problems*

Never or RarelySometimesOftenAlmost All the Time
I feel spiritually dead*

Never or RarelySometimesOftenAlmost All the Time
I have difficulty paying attention*

Never or RarelySometimesOftenAlmost All the Time
SCREENING SCORE
Your responses are for screening purposes only. Press the Submit button below. We would love the opportunity to discuss your results with you. 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: