• Diagnostic Survey

  • Welcome! This survey will assess the kinds of problems you've been having and will help your clinician perform a thorough diagnostic evaluation. It takes about 30-45 minutes to complete and focuses on common problems, such as:

    • Difficulties in your work or personal relationships
    • Mood problems such as depression
    • Anxiety, such as shyness, panic, chronic worrying, and phobias
    • Reactions to stressful or traumatic events
    • Pain or other physical symptoms
    • Addictions to drugs, alcohol, pornography or gaming

    Clinical Survey

    Part 1. Basic Information

  • Part 2. Relationship Survey

    Instructions: Please select below to indicate whether you're having problems in any of the following areas. Please answer all of the items.

  • Relationship Satisfaction Scale

  • Instructions: Please indicate how satisfied or dissatisfied you feel about your relationship with your mother.

  • Instructions: Please indicate how satisfied or dissatisfied you feel about your relationship with your father.

  • Anger Toward Yourself

    Instructions: Please indicate below how angry you've been feeling with yourself recently.

  • Anger Towards Others

    Instructions: Please indicate how angry you've been feeling with other people recently.

  • Part 3. Mood Survey

  • Feelings of Depression Right Now

    Instructions: Please indicate how much each item describes how you're feeling right now, at this very moment.

  • Chronic Depression

    Instructions: Please indicate below how much each item describes how you've felt in the past two years.

  • Feelings of Depression During the Past Two Weeks

    Major Depression

    Instructions: Please indicate how much each item describes how you've been feeling during the past two weeks.

  • Physical Symptoms

    Instructions: Please indicate how much each item describes how you've been feeling during the past two weeks.

  • Dramatically Elevated Mood

    Instructions: Please indicate how much each statement describes how you've been feeling recently.

  • Mania and Hypomania Checklist

    Indicate: Please indicate how much each statement describes how you've been feeling recently.

  • Part 4. Anxiety Survey

  • Anxious Feelings

    Instructions: Please indicate how you've been feeling recently.

  • Physical Symptoms of Anxiety

    Instructions: Please indicate how strong each type of symptom is when you're feeling worried, anxious, or panicky.

  • Chronic Worrying

    Instructions: Please indicate how you've been feeling recently.

  • Panic Attacks

    Instructions: Please indicate how you've been feeling recently.

  • Specific Fears During Panic Attacks

    Instructions: Please indicate how strong each of these feelings is during your panic attacks.

  • Fear of Being Away from Home Alone

    Agoraphobia

    Instructions: Please indicate how you've been feeling recently.

  • Feared Situations

    Instructions: Please indicate how strongly you fear each of the following situations.

  • Screening for Fears and Phobias

    Instructions: Please indicate whether any of these fears or phobias bother you.

  • Distress from Fears and Phobias

    Instructions: Please indicate how strongly you're bothered by any fears or phobias from the list you just completed.

  • Shyness

    Instructions: Please indicate how you've been feeling recently.

  • Specific Types of Social Anxiety

    Instructions: Please indicate how you've been feeling recently.

  • Part 5. Obsession and Compulsions

  • Obsessive Thoughts

    Instructions: Please indicate how you've been feeling recently.

  • Compulsive Rituals

    Instructions: Please indicate how you've been feeling recently.

  • Distress from Obsessions and Compulsions

    Instructions: Please indicate how you feel about your obsessions or compulsions.

  • Concerns About Your Appearance

    Instructions: Please indicate how you've been feeling recently.

  • Part 6. Stressful or Traumatic Events

    Instructions: Please list any traumatic or stressful events that have caused emotional problems for you, and indicate how old you were when each event occurred. Even though it may be upsetting, make sure you include any horrifying events, such as rape, abuse, death, violence, torture, or serious illness or injury.

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  • Distress from Stressful Events Adjustment Disorder

    Instructions: Please indicate how you've been feeling recently.

  • Post-Traumatic Stress Disorder

    Instructions: Please indicate whether you've been exposed to a terrifying, traumatic event, and how you've been feeling since that time.

    Please answer all of the items below:

  • Part 7. Somatic Concerns

    Health Concerns

    Instructions: Please indicate whether you've had any of the following concerns about your health.

  • Current Pain

  • Recent Pain

  • Emotional Impact of Pain

    Instructions: Please indicate how you've been feeling recently.

  • Part 8. Habits and Addictions

    Pornography Screening

  • Pornography Problems

    Instructions: Please indicate how accurately each statement describes how you feel.

  • Gaming Screening

  • Gaming Problems

    Instructions: Please indicate how accurately each statement describes how you feel.

  • Alcohol and Drug Use

  • Cravings and Urges to Use

    Instructions: Please indicate how much each statement describes how you have been feeling in the past week, including today.

  • Alcohol Consumption in the Past Week

  • Note: One drink = 12 ounces of beer; 4 - 5 ounces of wine; or 1.25 ounces of liquor. One cocktail could = 2 or 3 drinks, or more, depending on how much alcohol you put in it.

  • Alcohol Consumption in the Past Year

  • Note: One drink = 12 ounces of beer; 4 - 5 ounces of wine; or 1.25 ounces of liquor. One cocktail could = 2 or 3 drinks, or more, depending on how much alcohol you put in it.

  • Lifetime Alcohol Consumption

  • Note: One drink = 12 ounces of beer; 4 - 5 ounces of wine; or 1.25 ounces of liquor. One cocktail could = 2 or 3 drinks, or more, depending on how much alcohol you put in it.

  • Problems from Alcohol Use

    Instructions: Please indicate whether you've had the following kinds of problems because of alcohol.

  • Drug Use during the Past Week

    Instructions: Please indicate how often you've used drugs during the past week. If unsure, take your best guess. Indicate any use of drugs, even if prescribed.

  • Lifetime Drug Use

    Instructions: Please indicate how often you've used drugs during your lifetime. Think of the time when you were using each type of drug the most. If unsure, take your best guess. Indicate any use of drugs, even if prescribed.

  • Problems from Drug Use

    Instructions: Please indicate whether you've had the following kinds of problems because of drugs.

  • Part 9. Eating Problems

  • Binge Eating

    Instructions: Please indicate how much you agree with each of the following statements.

    Please answer all of the items below:

  • Frequency of Binging and Overeating

  • Bulimia

    Instructions: Please indicate how much you agree with each of the following statements.

    Please answer all of the items below:

  • Frequency

  • Anorexia

    Instructions: Please indicate how much you agree with each of the following statements.

    Please answer all of the items below:

  • Part 10. Other Symptoms

  • Dissociative Experiences

    Instructions: Please indicate how much you agree with each of the following statements.

  • Unusual Experiences

    Instructions: Please indicate below how much you agree with each of the following statements.

    Please answer all of the items below:

  • Personality

    Cluster A

  • Suspicious Feelings

    Instructions: Please indicate how much each statement describes how you have felt or behaved most of your life since your teenage years.

  • Feeling of Isolation

    Instructions: Please indicate how much each statement describes how you have felt or behaved most of your life since your teenage years.

  • Unique Experiences

    Instructions: Please indicate how much each statement describes how you have felt or behaved most of your life since your teenage years.

    Please answer all of the items below:

  • Cluster B

  • Wild Tendencies

    Instructions: Please indicate how much each statement describes how you have felt or behaved most of your life since your teenage years.