if you don't have time to fill this out…
Prior to our first counseling session, I will need you to complete each of these 7 forms. After filling out the first form, you will be provided with the next form, until the last has been completed. This may take 15-30 minutes or more.

Form 4 of 7

Patient Health Questionnaire

04 – Patient Health Questionnaire
Over the last 2 weeks, how often have you been bothered by any of the following problems?


Not At All=0 | Several Days=1 | More Than Half the Days=2 | Nearly Every Day=3

1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling or staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. 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 usual
9. Thoughts that you would be better off dead, or of hurting yourself
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
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