Sacred Circle Wellness

Sacred Circle

Psychological Evaluation
Information for Dr. Hillary McBride, R. Psych
Name

First NameLast Name
Date Submitted

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Stage (office coding)
SCL 90-R

Below is a list of problems and complaints that people sometimes have. Please read each one carefully and enter the number that best describes how much you were bothered by that problem during the past week. Please enter only ONE.

Please enter only ONE FOR THE PAST WEEK, HOW MUCH WERE YOU BOTHERED BY:

Rows	Not at All0	A Little Bit1	Moderately2	Quite a Bit3	Extremely4
1, Headaches
2.Nervousness or shakiness inside
3.Unwanted thoughts, words, or ideas that won’t leave your mind
4.Faintness or dizziness
5.Loss of sexual interest or pleasure
6.Feeling critical of others
7.The idea that someone else can control your thoughts
8.Feeling others are to blame for most of your troubles
9.Trouble remembering things
10.Worked about sloppiness or carelessness
11.Feeling easily annoyed or irritated
12.Pains in heart or chest
13.Feeling afraid in open spaces or on the streets
14.Feeling low in energy or slowed down
15.Thoughts of ending your life
16.Hearing words that others do not hear
17.Trembling
18.Feeling that most people cannot be trusted
19.Poor appetite
20.Crying easily
21.Feeling shy or uneasy with the opposite sex
22.Feeling of being trapped or caught
23.Suddenly scared for no reason
24.Temper outbursts that you could not control
25.Feeling afraid to go out of your house alone
26.Blaming yourself for things
27.Pains in lower back
28.Feeling blocked in getting things done
29.Feeling lonely
30.Feeling blue
31.Worrying too much about things
32.Feeling no interest in things
33.Feeling fearful
34.Your feelings being easily hurt
35.Other people being aware of your private thoughts
36.Feeling others do not understand you or are unsympathetic
37.Feeling that people are unfriendly or dislike you
38.Having to do things very slowly to insure correctness
39.Heart pounding or racing
40.Nausea or upset stomach
41.Feeling inferior to others
42.Soreness of your muscles
43.Feeling that you are watched or talked about by others
44.Trouble falling asleep
45.Having to check and double-check what you do
46.Difficulty making decisions
47.Feeling afraid to travel on buses, subways, or trains
48.Trouble getting your breath
49.Hot or cold spells
50.Having to avoid certain things, places, or activities because they frighten you
51.Your mind is going blank
52.Numbness or tingling in parts of your body
53.A lump in your throat
54.Feeling hopeless about the future
55.Trouble concentrating
56.Feeling weak in parts of your body
57.Feeling tense or keyed up
58.Heavy feelings in your arms or legs
59.Thoughts of death or dying
60.Overeating
61.Feeling uneasy when people are watching or talking about you
62.Having thoughts that are not your own
63.Having urges to beat, injure, or harm someone
64.Awakening in the early morning
65.Having to repeat the same actions such as touching, counting, washing
66.Sleep that is restless or disturbed
67.Having urges to break or smash things
68.Having ideas or beliefs that others do not share
69.Feeling very self-conscious with others
70.Feeling uneasy in crowds, such as shopping, or at a movie
71.Feeling everything is an effort
72.Spells of terror or panic
73.Feeling uncomfortable about eating or drinking in public
74.Getting into frequent arguments
75.Feeling nervous when you are left alone
76.Others not giving you proper credit for your achievements
77.Feeling lonely even when you are with people
78.Feeling so restless you couldn’t sit still
79.Feelings of worthlessness
80.Feeling that familiar things are strange or unreal
81.Shouting or throwing things
82.Feeling afraid you will faint in public
83.Feeling that people will take advantage of you if you let them
84.Having thoughts about sex that bother you a lot
85.The idea that you should be punished for your sins
86.Feeling pushed to get things done
87.The idea that something serious is wrong with your body
88.Never feeling close to another person
89.Feelings of guilt
90.The idea that something is wrong with your mind

PHQ-9

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Rows	Not at all0	Several Days1	More than half the days2	Nearly every day3
1 Little interest or pleasure in doing things
2 Feeling down, depressed, or hopeless
3 Trouble falling or staying asleep, or sleeping too much
4 Feeling tired or having little energy
5 Poor appetite or overeating
6 Feeling bad about yourself - or that you are a failure or have let yourself or your family down
7 Trouble concentrating on things, such as reading the newspaper or watching television
8 Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
9 Thoughts that you would be better off dead or of hurting yourself in some way

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things athome, or get along with other people?

Rows	Not Difficult at all	Somewhat Difficult	Very Difficult	Extremely Difficult
Please Rate

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from
Pfizer Inc. No permission required to reproduce, translate, display or distribute.
GAD - 7

1. Over the LAST TWO WEEKS, how often have you been bothered by any of the following problems?

Rows	Not at all0	Several Day1	More than half the days2	Nearly every day3
a. Feeling nervous, anxious or on edge
b. Not being able to stop or control worrying
c. Worrying too much about different things
d. Trouble relaxing
e. Being so restless that is hard to sit still
f. Becoming easily annoyed or irritable
g. Feeling afraid as if something awful might happen

ACE

While you were growing up, during your first 18 years of life:
1. Did a parent or other adult in the household often...Swear at you, insult you, put you down, or humiliate you? OR Act in a way that made you afraid that you might be physically hurt?
2. Did a parent or other adult in the household often...Push, grab, slap, or throw something at you? OR Ever hit you so hard that you had marks or were injured?
3. Did an adult or person at least 5 years older than you ever...Touch or fondle you or have you touch their body in a sexual way? OR Try to or actually have oral, anal, or vaginal sex with you?
4. Did you often feel that...No one in your family loved you or thought you were important or special? OR Your family didn’t look out for each other, feel close to each other, or support each other?
5. Did you often feel that...You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? OR Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
6. Were your parents ever separated or divorced?
7. Was your mother or stepmother:Often pushed, grabbed, slapped, or had something thrown at her? OR Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?OR Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
9. Was a household member depressed or mentally ill or did a household member attempt suicide?
10. Did a household member go to prison?
PCL - 5

Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month.

In the past month, how much were you bothered by:

Rows	Not at all1	A Little Bit2	Moderately3	Quite a bit4	Extremely5
1. Repeated, disturbing, and unwanted memories of the stressful experience?
2. Repeated, disturbing dreams of the stressful experience?
3. Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
4. Feeling very upset when something reminded you of the stressful experience?
5. Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
6. Avoiding memories, thoughts, or feelings related to the stressful experience?
7. Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
8. Trouble remembering important parts of the stressful experience?
9. Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
10. Blaming yourself or someone else for the stressful experience or what happened after it?
11. Having strong negative feelings such as fear, horror, anger, guilt, or shame?
12. Loss of interest in activities that you used to enjoy?
13. Feeling distant or cut off from other people?

Should be Empty:

Sacred Circle

SCL 90-R

PHQ-9

GAD - 7

ACE

PCL - 5