Name
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First Name
Last Name
Phone
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(###)
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Friends For All Counselor
I have little interest or pleasure in doing things.
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0: Not at all
1: Several days
2: More than half the days
3: Nearly every day
I feel down, depressed, or hopeless.
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0: Not at all
1: Several days
2: More than half the days
3: Nearly every day
I have trouble falling asleep, staying asleep, or sleeping too much.
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0: Not at all
1: Several days
2: More than half the days
3: Nearly every day
I feel tired or have very little energy.
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0: Not at all
1: Several days
2: More than half the days
3: Nearly every day
I have a poor appetite or am overeating.
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0: Not at all
1: Several days
2: More than half the days
3: Nearly every day
I feel bad abot myself- or I feel like a failure and have let myself and/or my family down.
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0: Not at all
1: Several days
2: More than half the days
3: Nearly every day
I have trouble concentrating on things, such as reading the newspaper or watching television.
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0: Not at all
1: Several days
2: More than half the days
3: Nearly every day
I move or speak so slowly that other people could have noticed. Or the opposite- I am so fidgety or restless and have been moving around more than usual.
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0: Not at all
1: Several days
2: More than half the days
3: Nearly every day
I have thoughts I would be better off dead or hurting myself in some way.
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0: Not at all
1: Several days
2: More than half the days
3: Nearly every day
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
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Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
