Mind Matters Nepal: Brief Mood Survey

1
Name (तपाईँको नाम)* This field is required.
First Name
Last Name
2
1. Sad or down in the dumps (दु:खी वा अन्धकरमा भएको जस्तो)* This field is required.
😢
Not at all (कुनै पनि हालतमा होइन)
Moderately (ठिक्क मात्रामा)
Somewhat (केही)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😢
Not at all (कुनै पनि हालतमा होइन)
Moderately (ठिक्क मात्रामा)
Somewhat (केही)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
3
2. Discouraged or hopeless (निराश वा आशाहीन)* This field is required.
😔
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😔
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
4
3. Low self-esteem, inferiority, worthlessness (आत्मसम्मान गिरेको, हीनताबोध, मूल्यहीन)* This field is required.
😞
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😞
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
5
4. Loss of motivation to do things (काम गर्न लगाव को कमी)* This field is required.
😰
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😰
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
6
5. Loss of pleasure or satisfaction in life (मान भित्र सुख वा सन्तुष्टिको कमि )* This field is required.
🫨
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
🫨
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
7
6 . Feel like you’d be better off dead? (के तपाई आफु मरेको भए राम्रो हुने थियो भन्ने जस्तो लाग्छ?)* This field is required.
😵
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😵
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
8
7. Have suicidal thoughts or fantasies? (आत्महत्या गर्ने विचार वा कल्पना गर्नु भएको छ ?)* This field is required.
🙄
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
🙄
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
9
8 . Have urges or plans to end your life? (आफ्नो जीवन अन्त गर्ने सोच आयको छ अथवा योजना बनाउनु भएको छ?)* This field is required.
😓
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😓
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
10
9. Anxious (चिन्तित)* This field is required.
😣
Not at all (कुनै पनि हालतमा होइन)
Moderately (ठिक्क मात्रामा)
Somewhat (केही)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😣
Not at all (कुनै पनि हालतमा होइन)
Moderately (ठिक्क मात्रामा)
Somewhat (केही)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
11
10. Frightened (त्रसित)* This field is required.
🫣
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
🫣
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
12
11. Worrying about things (कुनै कुराको चिन्ता)* This field is required.
😬
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😬
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
13
12. Tense or on edge (तनावग्रस्त वा भिरबाट खस्न लागेको जस्तो)* This field is required.
😵‍💫
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😵‍💫
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
14
13. Nervous (बेचैन)* This field is required.
🫨
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
🫨
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
15
14. Frustrated (हताश)* This field is required.
🤦‍♂️
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
🤦‍♂️
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
16
15. Annoyed (रुष्ट)* This field is required.
😡
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😡
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
17
16. Resentful (आक्रोशित)* This field is required.
🤬
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
🤬
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
18
17. Angry (रिस)* This field is required.
😤
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😤
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
19
18. Irritated (चिढिएको)* This field is required.
😬
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😬
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
20
19. Happy and joyful (रमाईला र हर्षित)* This field is required.
😊
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😊
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
21
20. Hopeful and optimistic (आशावादी र आशाप्रद)* This field is required.
🥹
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
🥹
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
22
21. Worthwhile, high self-esteem (सार्थक, उच्च स्वाभिमान)* This field is required.
😃
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😃
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
23
22. Motivated, productive (प्रेरित, फलदायी)* This field is required.
😄
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😄
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
24
23. Pleasure and satisfaction in life (जीवनमा सुख र सन्तुष्टि)* This field is required.
😇
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
😇
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
25
24. Put the name of an important relationship in your life: eg. Father आफ्नो जीवनमा एउटा महत्वपूर्ण सम्बन्धको नाम राख्नुहोस्: उदहारण: बुवा* This field is required.
26
25. Communication and openness (बातचीत र खुलापन)* This field is required.
🧏
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6
🧏
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6
27
26. Resolving conflicts (द्वन्द्व समाधान गर्ने)* This field is required.
🙇
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6
🙇
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6
28
27. Degree of affection and caring (स्नेह र हेरचाहको मात्रा)* This field is required.
👫
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6
👫
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6
29
28. Intimacy and closeness (आत्मीयता र निकटता)* This field is required.
👪
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6
👪
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6
30
29. Overall satisfaction (समग्र सन्तुष्टि)* This field is required.
👪
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6
👪
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4Row 0, Column 5Row 0, Column 6
31
31. How much psychotherapy homework have you done since your last session? पछिल्लो सत्रमा उल्लेख गरिएको थेरापीको गृहकार्य कति गर्नुभएको छ ? * This field is required.
1
2
3
4
5
Not done any homework (केहि गृहकार्य पनि गरेको छैन)
Done a lot of homework (धेरै गृहकार्य गरेको छु)
32
Is this form as a part of "Before-session" or "After-Session" (यो फारम सत्रभन्दा अघिको हो या सत्र पछिको हो?* This field is required.
Before-session (सत्रभन्दा अघिको)
After-Session (सत्र पछिको)
33
Evaluation of Therapy Session (थेरापी सत्रको मूल्याङ्कन)
34
Therapeutic empathy (समानुभूति)
35
1. My therapist seemed warm, supportive and concerned. मेरो चिकित्सक स्वहर्ध, सहयोगी हुन्थियो र मेरो बारेमा चासो राख्नु हुन्थियो।* This field is required.
🤗
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
🤗
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
36
2. My therapist seemed trustworthy. मेरो चिकित्सक भरपर्दो देखिनुहुन्थियो।* This field is required.
🤝
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
🤝
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
37
3. My therapist treated me with respect. मेरो चिकित्सकले मलाई आदरपूर्वक व्यवहार गर्नुभयो।* This field is required.
🙇‍♂
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
🙇‍♂
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
38
4. My therapist did a good job of listening. मेरो चिकित्सकले मेरो कुरा राम्रो संग सुन्नुभयो ।* This field is required.
👂
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
👂
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
39
5. My therapist understood how I felt inside. * This field is required.
🆗
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
🆗
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
40
Helpfulness of the session (सत्रको उपयोगीता)
41
6. I was able to express my feelings during the session. मैले सत्रको समयमा आफ्ना भावनाहरू व्यक्त गर्न सके।* This field is required.
💭
Not at all (कुनै पनि हालतमा होइन)
Somewhat (केही)
Moderately (ठिक्क मात्रामा)
A lot (धेरै)
Extremely (अत्यन्तै)
Row 0, Column 0Row 0, Column 1Row 0, Column 2Row 0, Column 3Row 0, Column 4
💭
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7. I talked about the problems that are bothering me. * This field is required.
🗣
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🗣
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8. The techniques we used were helpful. यस सत्रमा हामीले प्रयोग गरेका उपायहरू उपयोगी थिए।* This field is required.
🧰
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🧰
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9. The approach my therapist used made sense. मेरो चिकित्सकले प्रयोग गरेका दृष्टिकोणहरु अर्थपूर्ण थिए।* This field is required.
🙆‍♂
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🙆‍♂
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10. I learned some new ways to deal with my problems. मैले मेरा समस्याहरू समाधान गर्ने केही नयाँ तरिकाहरू सिकें।* This field is required.
😌
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Satisfaction with today’s session (आजको सत्रबाट सन्तुष्टि )
47
11. I believe the session was helpful to me. मलाई विश्वास छ कि यो सत्र मेरो लागि उपयोगी थियो।* This field is required.
🙋
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12. Overall, I was satisfied with today’s session. म आजको सत्रबाट सन्तुष्ट छु।* This field is required.
🤗
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🤗
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Your commitment (तपाईंको प्रतिबद्धता )
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13. I plan to do therapy homework before the next session. मैले अर्को सत्र अघि गृहकार्य गर्ने सोच गरेको छु।* This field is required.
✍
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14. I intend to use what I learned in today’s session. आजको सत्रमा मैले सिकेका कुराहरू म मेरो जीवनमा लागु गर्ने सोचमा छु।* This field is required.
📚
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📚
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Negative feelings during the session (सत्रको समयमा आएका नकारात्मक भावनाहरू )
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15. At times, my therapist didn’t seem to understand how I felt. सत्रको बेलामा कुनै बेला मेरो चिकित्सकले मेरो भवना नाभुजेको जस्तो महसुस भयो ।* This field is required.
✋🏼
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✋🏼
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16. At times, I felt uncomfortable during the session. मलाई सत्रको समयमा कहिले काहीँ असहज महसुस भयो।* This field is required.
😰
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Difficulties with the questions (प्रश्नहरूको साथ कठिनाइहरू )
56
17. It was hard to answer some of these questions honestly. यो सर्वेक्षणको केही प्रश्नहरूको इमानदारीपूर्वक जवाफ दिन गाह्रो थियो।* This field is required.
😓
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😓
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18. Sometimes my answers didn’t show how I really felt inside. यो सर्वेक्षणको दौरान मेरा कुनै जवाफहरूले मेरो भित्रि भावना दर्सौन सकेको थिएन।* This field is required.
😣
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😣
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19. It would be too upsetting for me to criticize my therapist. यस प्रतिक्रियाको दौरान मैले मेरो चिकित्सकको आलोचना गर्न धेरै अप्ठ्यारो हुन्छ।* This field is required.
😞
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😞
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20 . What did you like the least about the session? तपाईलाई * This field is required.
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21. What did you like the best about the session? तपाईलाई * This field is required.
Should be Empty: