Life Counseling Services

Personal Information Name: Sex: Male Female Age: Date:

Please check appropriate response as felt during the past two weeks.

I feel sad	Never or Rarely Sometimes Often Almost always
I feel like a failure	Never or Rarely Sometimes Often Almost always
I have lost interest in my work	Never or Rarely Sometimes Often Almost always
I do not look forward to the future	Never or Rarely Sometimes Often Almost always
I feel guilty	Never or Rarely Sometimes Often Almost always
I have lost interest in my hobbies	Never or Rarely Sometimes Often Almost always
I feel that others do not like me	Never or Rarely Sometimes Often Almost always
I am unhappy with myself	Never or Rarely Sometimes Often Almost always
I doubt my own judgment	Never or Rarely Sometimes Often Almost always
I am easily frustrated	Never or Rarely Sometimes Often Almost always
I wish I were dead	Never or Rarely Sometimes Often Almost always
I feel lonely	Never or Rarely Sometimes Often Almost always
I avoid being around people	Never or Rarely Sometimes Often Almost always
My eating patterns have changed over the past two weeks, ie. Overeating or loss of appetite	Never or Rarely Sometimes Often Almost always
I have suicidal thoughts	Never or Rarely Sometimes Often Almost always
I deserve to be punished	Never or Rarely Sometimes Often Almost always
I have difficulty making decisions	Never or Rarely Sometimes Often Almost always
I feel worn out	Never or Rarely Sometimes Often Almost always
I feel emotionally shut down	Never or Rarely Sometimes Often Almost always
I feel worthless	Never or Rarely Sometimes Often Almost always
I am not interested in sex	Never or Rarely Sometimes Often Almost always
I feel hopeless	Never or Rarely Sometimes Often Almost always
I blame myself for other people’s problems	Never or Rarely Sometimes Often Almost always
I feel spiritually dead	Never or Rarely Sometimes Often Almost always
I have difficulty paying attention	Never or Rarely Sometimes Often Almost always