Counseling Evaluation Form
Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
During the past TWO (2) WEEKS, how often (or how much) have you been bothered by the following problems?
*
Rows
None at all
Rare, less than a day or two
Several days
More than half of the days
Nearly every day
Little interest or pleasure in doing things?
Feeling down, depressed, or hopeless?
Feeling more irritated, grouchy or angry than usual?
Sleeping less than usual, but still have a lot of energy?
Starting lots more projects than usual or doing more risky things than usual?
Feeling nervous, anxious, frightened, worried or on edge?
Avoiding situations that make you anxious?
Feeling panic or being frightened?
Unexplained aches and pains (e.g. head, back, joints, abdomen, legs)?
Feeling that your illnesses are not being taken seriously enough?
Thoughts of actually hurting yourself?
Hearing things other people couldn't hear, such as voices even when no one was around?
Feeling that someone could hear your thoughts or that you could hear what another person was thinking?
Problems with sleep that affected your sleep quality over all?
Problems with memory (e.g. learning new information) or with location (e.g. finding your way home)?
Unpleasant thoughts, urges, or images that repeatedly enter your mind?
Feeling driven to perform certain behaviors or mental acts over and over again?
Feeling detached or distant from yourself, your body, your physical surroundings, or your memories?
Not knowing who you really are or what you want out of life?
Not feeling close to other people or enjoying your relationships with them?
Drinking at least 4 drinks of any kind of alcohol in a single day?
Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco?
Using any of the following ON YOUR OWN, that is without a doctor's prescription, in greater amounts or longer than prescribed [e.g. painkillers (like Vicodin), stimulants (like Ritalin/Adderall), sedatives or tranquilizers (like sleeping pills or Valium), or drugs like marijuana, cocaine, or crack, club drugs (like ecstasy), hallucinogens (like LSD), heroin, inhalants or solvent (like glue) or methamphetamine (like speed)]?
In the last 4 weeks, how much have you been concerned by any of the following problems?
Rows
Not concerned
Somewhat concerned
Very concerned
Problems in family and/or marriage
Problems related to your social life
Having no one to turn to when you have a problem (being close to people)
There are things too painful to talk about
Educational problems or stress
Occupational problems
Economic problems or financial worries
Legal difficulties
Worry about your health or weight
Concerns about your sexuality
Spiritual concerns
Rate how you are doing overall, my personal well-being is:
(low) 1
2
3
4
5
6
7
8
9
(high) 10
Do you consider yourself a spiritual person?
Yes
No
What is your place of worship?
Are there current or past relationships that are a particular concern for you? Please briefly describe:
What would you like to address in counseling?
Evaluate Now!
Should be Empty: