Self-Referral Form

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things :Please select...Not at allSeveral daysMore than half the daysNearly every day
Feeling down, depressed or hopeless Please select...Not at allSeveral daysMore than half the daysNearly every day
Trouble falling or staying asleep or sleeping too much
Please select...Not at allSeveral daysMore than half the daysNearly every day
Feeling tired or having little energy Please select...Not at allSeveral daysMore than half the daysNearly every day
Poor appetite or over eatingPlease select...Not at allSeveral daysMore than half the daysNearly every day
Feeling bad about yourself or that you are a failure or have let yourself or your family downPlease select...Not at allSeveral daysMore than half the daysNearly every day
Trouble concentrating on things such as reading the newspaper or watching televisionPlease select...Not at allSeveral daysMore than half the daysNearly every day
Moving or speaking so slowly that other people could have noticed? or the opposite-being so fidgety or restless that you have been moving around a lot more than usualPlease select...Not at allSeveral daysMore than half the daysNearly every day
Thoughts that you would be better off dead or hurting yourself in some wayPlease select...Not at allSeveral daysMore than half the daysNearly every day
Feeling nervous, anxious or on edgePlease select...Not at allSeveral daysMore than half the daysNearly every day
Not being able to stop or control worryingPlease select...Not at allSeveral daysMore than half the daysNearly every day
Worrying too much about different thingsPlease select...Not at allSeveral daysMore than half the daysNearly every day
Trouble relaxingPlease select...Not at allSeveral daysMore than half the daysNearly every day
Being so restless that it is hard to sit stillPlease select...Not at allSeveral daysMore than half the daysNearly every day
Becoming easily annoyed or irritablePlease select...Not at allSeveral daysMore than half the daysNearly every day
Feeling afraid as if something awful might happenPlease select...Not at allSeveral daysMore than half the daysNearly every day
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