CORe 10 Form Pop Up

Name

Date

Gender GenderMaleFemale

I have felt tense, anxious or nervous I have felt tense, anxious or nervous0 - Not at all1 - Only Occasionally2 - Sometimes3 - Often4 - Most or all of the time

I have felt I have someone to turn to for support when needed I have felt I have someone to turn to for support when needed4 - Not at all3 - Only Occasionally2 - Sometimes1 - Often0 - Most or all of the time

I have felt able to cope when things go wrong I have felt able to cope when things go wrong4 - Not at all3 - Only Occasionally2 - Sometimes1 - Often0 - Most or all of the time

Talking to people has felt too much for me Talking to people has felt too much for me0 - Not at all1 - Only Occasionally2 - Sometimes3 - Often4 - Most or all of the time

I have felt panic or terror I have felt panic or terror0 - Not at all1 - Only Occasionally2 - Sometimes3 - Often4 - Most or all of the time

I have made plans to end my life I have made plans to end my life0 - Not at all1 - Only Occasionally2 - Sometimes3 - Often4 - Most or all of the time

I have had difficulty getting to sleep or staying asleep I have had difficulty getting to sleep or staying asleep0 - Not at all1 - Only Occasionally2 - Sometimes3 - Often4 - Most or all of the time

I have felt despairing or hopeless I have felt despairing or hopeless0 - Not at all1 - Only Occasionally2 - Sometimes3 - Often4 - Most or all of the time

I have felt unhappy I have felt unhappy 0 - Not at all1 - Only Occasionally2 - Sometimes3 - Often4 - Most or all of the time

Unwanted images or memories have been distressing me Unwanted images or memories have been distressing me0 - Not at all1 - Only Occasionally2 - Sometimes3 - Often4 - Most or all of the time

I am prepared for this information to be recorded and kept by my therapist together with details of treatment sessions. I am prepared for this information to be recorded and kept by my therapist together with details of treatment sessions. Yes