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Survey
Here are a few questions for you to give us some valuable feedback. Please try to be as open and honest as you can because your opinions matter very much.
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Your initials (only)
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Do not put your name here for confidentiality reasons.
Appointment date
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How has your mood been over the
last 4 weeks
?
How often did you feel hopeless?
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None of the time
A little of the time
Some of the time
Most of the time
All of the time
How often did you feel restless and fidgety?
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None of the time
A little of the time
Some of the time
Most of the time
All of the time
Did you feel tired for no good reason?
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None of the time
A little of the time
Some of the time
Most of the time
All of the time
How often did you feel so nervous nothing could calm you down?
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None of the time
A little of the time
Some of the time
Most of the time
All of the time
How often did you feel depressed?
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None of the time
A little of the time
Some of the time
Most of the time
All of the time
How often did you feel so restless you could not sit still?
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None of the time
A little of the time
Some of the time
Most of the time
All of the time
How often did you feel nervous?
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None of the time
A little of the time
Some of the time
Most of the time
All of the time
How often did you feel everything is an effort?
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None of the time
A little of the time
Some of the time
Most of the time
All of the time
You were so sad nothing could cheer you up?
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None of the time
A little of the time
Some of the time
Most of the time
All of the time
How often did you feel worthless?
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None of the time
A little of the time
Some of the time
Most of the time
All of the time
How many days were you TOTALLY UNABLE to work, study or manage your day to day activities?
*
Send
Thank you!
Home
Types of appointments
What is a Psychotherapist
Bookings
Fees
Confidentiality
Qualifications
Contact