Your Name (required)
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1. What is your gender?
2. How old are you?
3. What is your relationship status?
4. Have you ever en in counseling or therapy before?
5. How do you rate your physical health?
6. How do you rate your sleeping habits?
7. How would you rate your current eating habits?
8. How would you rate your current financial status?
9. Are you currently experiencing overwhelming sadness, grief, or depression?
10. Within the past two weeks have you been moving or speaking so slowly that other people could have noticed?
11. Do you have little interest or pleasure in doing things?
12. Have you been feeling down, depression or hopeless?
13. Trouble falling asleep, staying asleep, or sleeping to much?
14. Are you feeling tired or having little energy?
15. Do you have a poor appetite or have you been overeating?
16. Having you been feeling that you are a failure or have let yourself or your family down?
17. Do you have trouble concentrating on things, such as reading the newspaper or watching television?
18. Thought that you want to hurt yourself, or you would e better of dead?
19. Are you having problems with intimacy?
20. Are you ready for assistance in the right direction?