top of page
Image by v2osk

Self-Assessment

Do I have a Problem?

T F Kerr Counseling provides Self-Assessment Questionnaires to determine if you have a problem with depression, anxiety, alcoholism, or drug addiction. 
Marble Surface

Depression
Self-Questionnaire

**IF YOU ANSWER YES TO THREE OR MORE QUESTIONS PLEASE CONTACT ME TO ARRANGE AN APPOINTMENT**

 1. I do things slowly.
_ Yes   _ No   _ Sometimes

2. My future seems hopeless.
_ Yes   _ No    _ Sometimes

3. It is hard for me to concentrate on reading.
_ Yes   _ No   _ Sometimes

4. The pleasure and joy has gone out of my life.
_ Yes   _ No   _ Sometimes

5. I have difficulty making decisions.
_ Yes    _ No   _ Sometimes
 
6. I have lost interest in aspects of life that used to be important to me.

_ Yes   _ No   _ Sometimes

7. I feel sad, blue, and unhappy. 
_ Yes   _ No    _ Sometimes

8. I feel fatigued.
_ Yes    _ No    _ Sometimes

9. It takes great effort for me to do simple things.
_ Yes   _ No    _ Sometimes

10. I feel like a failure.
_ Yes    _ No   _ Sometimes

11. I feel lifeless — more dead than alive.
_ Yes    _ No   _ Sometimes

12. My sleep has been disturbed — too little, too much, or broken sleep.
_ Yes   _ No    _ Sometimes

13. I feel depressed even when good things happen to me.
_ Yes    _ No    _ Sometimes
 
14. Without trying to diet, I have lost, or gained, weight.
_ Yes   _ No    _ Sometimes

Drug Abuse
Self-Questionnaire

**IF YOU ANSWER YES TO TWO OR MORE QUESTIONS PLEASE CONTACT ME TO ARRANGE AN APPOINTMENT**

1. Have you used drugs other than those required for medicinal reasons?
_ Yes   _ No

2. Have you abused prescription drugs?
_ Yes   _ No

3. Can you get through the week without using drugs?
_ Yes   _ No

4. Are you always able to stop using drugs when you want to? 
_ Yes   _ No

5. Have you had "blackouts" or "flashbacks" as a result of drug use? 
_ Yes   _ No

6. Do you ever feel bad or guilty about your drug use? 
_ Yes   _ No

7. Has drug abuse created problems between you and your loved ones? 
_ Yes   _ No

8. Have you lost friends or family because of your use of drugs?  
_ Yes   _ No

9. Have you lost a job because of drug abuse?
_ Yes   _ No  

10. Have you gotten into fights when under the influence of drugs?
_ Yes   _ No

11. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 
_ Yes   _ No

Alcohol Abuse
Self-Questionnaire

 **IF YOU ANSWER YES TO FIVE OR MORE QUESTIONS PLEASE CONTACT ME TO ARRANGE AN APPOINTMENT**

1.  Do you drink heavily when you are disappointed, under pressure or have had an argument with someone? 
_ Yes   _ No

2.  Can you handle more alcohol now than when you first started to drink?
_ Yes   _ No

3.  Have you ever experienced a black out as a result of drinking too much? 
_ Yes   _ No

4.  Do you sometimes feel uncomfortable if alcohol is not available? 
_ Yes   _ No

5.  Are you more in a hurry to get your first drink of the day than you used to be? 
_ Yes   _ No

6.  Do you sometimes feel a little guilty about your drinking? 
_ Yes   _ No

7.  Has a family member or close friend express concern or complained about your drinking? 
_ Yes   _ No

8.  Do you often want to continue drinking after your friends say they’ve had enough?   
_ Yes   _ No

9.  Do you usually have a reason for the occasions when you drink heavily? 
_ Yes   _ No

10.  When you’re sober, do you sometimes regret things you did or said while drinking?
_ Yes   _ No

11.  Have you tried switching brands or drinks, or following different plans to control your drinking?
_ Yes   _ No

12.  Have you sometimes failed to keep promises you made to yourself or loved ones about controlling or cutting down on your drinking?         
_ Yes   _ No
 
13.  Have you ever had a DWI (driving while intoxicated) or DUI (driving under the influence of alcohol) violation, or any other legal problem related to your drinking?   
_ Yes   _ No

14.  Do you try to avoid family or close friends while you are drinking? 
_ Yes   _ No

15.  Are you having more financial, work, school, and/or family problems as a result of your drinking?
_ Yes   _ No

16.  Has your physician ever advised you to cut down on your drinking?
_ Yes   _ No

17.  Do you sometimes have tremors (shakes) in the morning and find that it helps to have a drink in order to calm the tremors down? 
_ Yes   _ No

18.  Do you sometimes stay drunk for several days at a time? 
_ Yes   _ No
 
19.  Do you ever feel depressed or anxious before, during or after periods of heavy drinking?
_ Yes   _ No

20.  Have any of your blood relatives ever had a problem with alcohol?
_ Yes   _ No
bottom of page