Use this brief, time-saving questionnaire to help determine if you need to see a mental health professional for further diagnosis and treatment of a life problem or issue.

The 12 items below refer to how you have felt and behaved during the PAST MONTH. For each item, indicate the extent to which it is true, by checking the appropriate box next to the item.

I am concerned about a behavior, feeling, or something I am doing.

 
 
 
 
 
 

This behavior or feeling has been getting worse in the past few weeks.

 
 
 
 
 
 

I have tried stopping or reducing this behavior or feeling on my own.

 
 
 
 
 
 

My attempts at stopping or reducing this behavior or feeling have been successful.

 
 
 
 
 
 

I rely on my friends or family to help me with my current troubles.

 
 
 
 
 
 

I am finding it more difficult to cope with things than usual.

 
 
 
 
 
 

I am having trouble concentrating at work or school.

 
 
 
 
 
 

I like to think things through or talk about things that bother me.

 
 
 
 
 
 

I have talked to my family doctor or healthcare professional about the behavior or feeling that is troubling me.

 
 

I have talked to my friends or family about the behavior or feeling that is troubling me.

 
 

I have read books or went on the Internet to discover more about the behavior or feeling that is troubling me.

 
 
 
 
 
 

I have been in therapy before and it has helped me.

 
 
 
 
 
 

Question 1 of 12