NAME:

PHONE:

DATE:

Please answer each question as best you can.

Assessment Questions

1. How would you describe your current psychological symptoms, such as depression, anxiety, or mood disturbances?

• No symptoms (0 pts.)
• Mild symptoms (1 pt.)
• Moderate symptoms (2 pts.)
• Serious symptoms (3 pts.)
• Severe symptoms (4 pts.)
• Extremely severe symptoms (5 pts.)

2. How well are you able to manage your relationships and interact with others on a daily basis?

• Superior functioning (0 pts.)
• Good functioning (1 pt.)
• Some difficulty in social functioning (2 pts.)
• Major impairment in social functioning (3 pts.)

3. How would you describe your performance and satisfaction in your work or daily activities?

• Very good functioning (0 pts.)
• Good functioning (1 pt.)
• Some difficulty in occupational functioning (2 pts.)
• Major impairment in occupational functioning (3 pts.)

4. Are you able to independently manage your daily activities such as personal hygiene, cooking, and cleaning?

• No difficulty (0 pts.)
• Mild difficulty (1 pt.)
• Moderate difficulty (2 pts.)
• Major difficulty (3 pts.)

5. Do you experience any cognitive difficulties, such as problems with memory or decision-making?

• No impairment (0 pts.)
• Mild impairment (1 pt.)
• Moderate impairment (2 pts.)
• Severe impairment (3 pts.)

6. How would you describe your ability to make sound judgments and understand your own mental health?

• Good judgment and insight (0 pts.)
• Adequate judgment and insight (1 pt.)
• Impaired judgment and insight (2 pts.)

RESULTS

Score Range	Description
100-91	Superior functioning in a wide range of activities, life’s problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms.
90-81	Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members).
80-71	If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).
70-61	If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).
60-51	Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).
50-41	Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).
40-31	Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school).
30-21	Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day; no job, home, or friends).
20-11	Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).
10-1	Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.