Depression Screening

Depression Screening

CONFIDENTIAL

Client Full Name

First NameLast Name

Gender:

Client Email Address

example@example.com

Which therapist are you scheduled with?

Other

Please check the appropriate responses below as it relates to the past two weeks:

I feel sad

I feel like a failure

I have lost interest in my work

I do not look forward to the future

I feel guilty

I have lost interest in my hobbies

I feel that others don't like me

I am unhappy with myself

I doubt my own judgment

I am easily frustrated

I wish I were dead

I feel lonely

I avoid being around other people

My eating patterns have changed over the past month, such as overeating, or loss of appetite

I have suicidal thoughts

I deserve to be punished

I have difficulty making decisions

I feel worn out

I feel emotionally shut down

I feel worthless

I am not interested in sex

I feel hopeless

I blame myself for other people's problems

I feel spiritually dead

I have difficulty paying attention

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