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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.
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
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