Savannah Miller, LLC Licensed Independent Clinical Social Worker -LW 60780445

savannahmillerllc@gmail.com (509) 630-5678

Please Print Today’s Date: Dx (Code and Description):

CLIENT INFORMATION Last name:

First name:

Middle:

☐ Mr. ☐ Miss ☐ Ms. ☐Mrs. Social Security no.:

Legal name? If not, what is your legal name?

(Former name):

Birth date:

Age:

Sex:

☐ Yes ☐ No ☐ M

☐ F

Street address: Home Phone no.: ( ) Ok to leave a msg: yes no

Email Address: It’s ok for Savannah to contact me about resources that may help in the counseling process: ☐ yes ☐ no

City: State: Zip Code:

Cell Phone no.: ( ) Ok to leave a msg: yes no

Alt no.: ( ) Msg OK?: yes no

Work Address: City: State: County: ZIP Code:

Occupation: Employer or Company: Work phone no.:

( )

Any Religious or Affiliation:

Hobbies:

INSURANCE INFORMATION

We would also like to make a copy of your insurance card Person responsible for bill:

Birth date:

Address (if different):

Home phone no.:

( )

City: State: ZIP:

Occupation: Employer: Employer address: Employer phone no.:

( )

Is this client covered by insurance? ☐ Yes ☐ No

Please indicate primary insurance: EAP Authorization#:

Subscriber’s name: Subscriber’s ID#: Birth date: Group no.: Policy no.: Co-payment:

$

Client’s relationship to subscriber: ☐ Self ☐ Spouse ☐ Child ☐ Other

Name of secondary insurance (if applicable):

Subscriber’s name and ID#: Group no.: Policy no.:

Client’s relationship to this subscriber: ☐ Self ☐ Spouse ☐ Child ☐ Other

CLIENT DEMOGRAPHICS

Marital Status Ethnicity Monthly Household Income Sexual Orientation 1 Single 1 Caucasian 1 $0 - $1,499 1 Heterosexual 2 Married 2 African American 2 $1,500 - $2,499 2 Gay /Lesbian 3 Separated 3 Asian/Pacific Islander 3 $2,500 - $3,499 3 Bi-Sexual 4 Divorced 4 Hispanic/Latino 4 $3,500+ 4 Transgender 5 Remarried 5 Alaskan Native or Native American 5 Other_________________ 6 Cohabited 6 Multi-racial

Do you have a disability, which qualifies you for special accommodation or compensation? ___________________________________________________________________________________________ Referral Source (Please check the box or boxes that best describe how you chose us as your service provider.) 1 Relative 5 Attorney 9 Website 13 NWFL Website 2 Friend 6 Church 10 Radio Show 14 Internet Search 3 Advocate 7 Dietician 11 Yellow Pages 15 Counseling Seattle 4 Court 8 Primary Doc 12 Psychology Today 16 Insurance Company

17 Other Name of referral person, church, doctor or agency_________________________________________________

IMMEDIATE FAMILY MEMBERS

Name Age Living with you Y/N Disabilities Y/N Health Concerns Y/N ____________________ ______ _________________ _________________ ___________________________

____________________ ______ _________________ _________________ ___________________________

____________________ ______ _________________ _________________ ___________________________

____________________ ______ _________________ _________________ ___________________________

____________________ ______ _________________ _________________ ___________________________

I give my permission for the above information to be used in aggregate form for research, required reporting and funding purposes. I understand that my name, the names of my children and any other identifying information will be kept confidential. Please talk with your therapist if you have a concern with this statement.

Signature___________________________________________________________Date_____________________________

IN CASE OF EMERGENCY Name of local friend or relative (not living at same address):

Relationship to patient: Home phone # Cell phone #

( ) ( )

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Savannah Miller. I understand that I am financially responsible for any balance. I also authorize Savannah Miller or the insurance company to release any information required to process my claims.

Signature:_________________________________________________ Date_______________________ *My signature indicates that the above information is correct.

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Notice of Privacy Practices This notice describes how your medical records may be used and disclosed, and how you can get access to this information.

The law protects the privacy of information we create and obtain in providing care and services to you. Your protected health information includes your diagnoses, treatment, information from other providers, and billing and payment information relating to these services. Federal and state laws allow us to use and disclose protected health information for purposes of treatment and health care operations. State law requires us to get your authorization to disclose this information for payment purposes. We understand that your personal health information is very sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so. Domestic Violence Treatment Laws do require us to give some specific information to victims and authorities, which is explained at the time of admission.

Your Health Information Rights The healthcare and billing records we create and store are the property of Savannah Miller. The protected health information in it belongs to you. You have a right to:

● Receive, read, and ask questions about this Notice. ● Ask us to restrict certain uses and disclosures. You must deliver this request in writing to us. ● Request and receive from us a paper copy of the most current Notice of Privacy Practices. ● Request that you be allowed to see and get a copy of your records. ● Have us review a denial of access to your records. ● Ask us to change something in your records. Please give us this request in writing. If your request is denied you may write a statement

of disagreement. It will be stored in your medical record and included with any release of your records. ● You may request a list of disclosures of your records without charge once every 12 months. Requests made more frequently will require

a fee to process. Please sign, date, and give us your request in writing. The list may not include disclosures for treatment, payment or health care operations.

● You may ask that your records be given to you by another means or at another location. ● Cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect

information that has already been released. It also does not affect any action taken before we have it. Sometimes, you cannot cancel an authorization if its purpose was to obtain payment.

If you believe your privacy rights have been violated, you may discuss your concerns with Savannah Miller. You may also deliver a written complaint addressed to Savannah Miller. You may also file a complaint with the U.S. Secretary of Health and Human Services.

Our Responsibilities We are required to:

● Keep your protected health information private unless authorized to give it out. ● Allow you to read this Notice and give you a copy if you want one. ● Update this Notice if we make changes. You may receive the most recent copy of this Notice by calling or coming by the office. ● Notify family and others for public health and safety purposes as required by law:

o To prevent or reduce a serious, immediate threat to someone’s health or safety o To prevent or control disease, injury, or disability o To ensure that you receive proper medical care.

● Ask your permission to share information of a personal nature for researchers’ purposes. ● Give Coroners information consistent with applicable law to allow them to carry out their duties. ● Report suspected abuse or neglect to public authorities. ● Give Correctional Institutions information for health and safety purposes if you are in jail or prison. ● Give information for law enforcement purposes or in the course of judicial proceedings such as when we receive a subpoena, court order,

or other legal process, or you are the victim of a crime. ● Give information for specialized government functions for national security purposes. ● Get your written authorization for other uses and disclosures not in this Notice.

Examples of Use and Disclosures of Protected Health Information for Treatment, Payment, and Health Care Operations:

For treatment:

● Information obtained will be recorded in your medical record and used to help create a treatment plan for you. ● Colleagues will occasionally discuss cases in a peer review format to assure the best approach for your treatment.

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For payment:

● Insurance plans sometimes require information from us about your diagnosis, treatment and recommendations.

For health care operations:

● We use your medical records to assess quality and improve services. ● We may use and disclose medical records to review the performance of our staff. ● We may contact you to remind you about appointments and give you information about treatment alternatives or other health-related

benefits and services.

We may use and disclose your information for medical quality review by your health plan; accounting, legal, risk management, and insurance services; audit functions, including fraud and abuse detection and compliance programs.

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Acknowledgement of Receipt of “Notice of Privacy Practices”

We keep a record of your assessment, progress notes, domestic violence records and mental health care services we provide you. You may ask to see and copy that record at your expense. You may also ask to correct that record. We will not disclose your records to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your records or get more information about it by contacting Gina Guddat. The Notice of Privacy Practices above describes in more detail how your health information may be used and disclosed, and how you can access your information. By my signature below I acknowledge I have read or received a copy of the Notice of Privacy Practices. __________________________________________________________ ____________________________________ ____________________________ Signature Date Time

__________________________________________________________ ____________________________________ Printed name of client Relationship to client (self, parent, legal guardian, personal representative)

This form will be retained in your medical record.

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Savannah Miller, LLC Licensed Independent Clinical Social Worker – LW 60780445

DISCLOSURE STATEMENT

Welcome! Before we start counseling it is both my desire and a requirement of Washington State law to provide you with the following information. Signing this form establishes our contract for therapy services. The Washington State Counselor Credentialing Act (WAC 246-810) requires that any counselor practicing counseling for a fee must be registered or certified with the Department of Health. This law was designed for the protection of the public health and safety, and to empower the citizens of the state of Washington by providing a complaint process against those counselors who would commit acts of unprofessional conduct. However, registration of an individual with the Department does not include recognition of any practice standards, nor necessarily imply the effectiveness of any treatment (WAC 246-810-031). It is every individual’s right and responsibility to choose the provider and treatment modality which best suits their needs. Formal Training: I am a Licensed Independent Clinical Social Worker (LICSW) in the state of Washington. I hold a Masters Degree in Clinical Social Work from The University of New England in Maine. I also have a Bachelor of Science degree in Pre-Professional Psychology from the University of Montana. Additionally, I have a training in dialectical behavioral therapy, neuroscience, compassion focused therapy and cognitive behavioral therapy. Professional Practice: My current experience includes working with couples, individuals, adolescents, families and groups. I began as a mental health worker at the age of nineteen on a psychiatric unit for children. Since that time, I served in a group home, therapeutic daycare center, sexual assault recovery center, in schools, in homes and have worked for the last four years practicing outpatient individual, group and family counseling for the county mental health department. I also operate as a independent consultant for a health and wellness company and can provide guidance and referrals for improving your physical as well as mental health. I am qualified to work with children, teens, families, individuals, couples and the elderly. Counseling Approach: My therapeutic orientation is best described as a compassion focused and an integrative approach to counseling. I feel it is important to consider all aspects of a person’s life including social, emotional, physical, mental and spiritual factors. I find that developing insight about the nature of one’s problems within the context of an empathetic and collaborative therapeutic relationship can lead to an increased sense worthiness, healthier relationships, and a more satisfying life. I believe in the right of each client to be treated with respect and dignity regardless of ethnicity, religion, disability, sexual orientation or economic status. I tailor my treatment approach to best fit the needs and desires of my clients. Some of these approaches may include: compassion focused therapy, cognitive behavioral therapy, dialectical behavioral therapy. I believe that mental health is as important as physical health and every member of our society would benefit from attending to it. We all have a mind and therefore, learning how to increase the health of our mind is essential. Confidentiality: I am bound by professional ethics to protect client rights to confidential communications in regards to their involvement in counseling. All issues discussed in the course of counseling are strictly confidential. By law, health care information pertaining to you may be released only with your written consent or the consent of a parent or guardian. For this reason, if you want me to release information about your participation in therapy, I will require a signed “Release of Information” from you. A release is legally valid for ninety (90) days from the date of signature. However, the law (RCW 18.19.180) provides exceptions to client confidentiality where information may be released without your consent

1. In the event of a medical emergency, information deemed necessary for treatment may be released. 2. In the event of a threat of harm to oneself or someone else, if that threat is perceived to be serious, the proper individuals

must be contacted. This may include the individual against whom a threat is made. 3. In the event of suspected abuse of a child, dependent adult or elder, the proper authorities must be contacted. The abuse

does not have to be personally witnessed by the counselor. 4. If you register a complaint with the Washington State Department of Health, information will be released as requested or

required by the State to resolve the issue. 5. If ordered by a judge or other judicial officers, information regarding your treatment must be disclosed. 6. If an attorney in the state of Washington duly subpoenas your records, they will be released unless you file a protection

order within 14 days of the subpoena. 7. In the event of a client’s death or disability, information will be released as authorized by the client’s personal

representative or beneficiary.

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8. A counselor is not required to treat as confidential a communication that reveals the contemplation or commission of a crime or harmful act.

9. Evidence that a minor client was a victim of a crime may be released to the proper authorities. Records Review & Correction: I keep a record of the health care services that I provide to you. You have a right, by law (RCW 70.02.070), to see and copy that record. Also, you may ask to make correction(s) to your record. A reasonable fee will be charged for reviewing and/or photocopying any portion of your record. Case Consultation: I advocate and practice professional consultations for the purposes of professional training, accountability and providing the best counseling service possible to clients. I may be discussing your situation with other professionals while being very careful not to disclose your identity. Please speak with me if you have concerns regarding this practice. Use of data derived from counseling for purposes of training, research, or publication is confined to content that is disguised to ensure the anonymity of the individuals involved. Unprofessional Conduct & Complaint Process: If you have any concerns about the course of your treatment I ask that you attempt to resolve them with me individually. If resolution is still not reached you have the right to file a complaint with the Dept. of Health (Dept. of Health, Health Professions Quality Assurance Division, Counselor Registration/Certification, PO Box 47869, Olympia, WA 98504-7869, 360-753-1761). Dual Relationships: Counselors are aware of their influential positions with respect to clients, and they avoid exploiting the trust and dependency of clients. Counselors make every effort to avoid dual relationships with clients that could impair professional judgment or increase the risk of harm to clients. (Examples of such relationships include, but are not limited to: volunteering, familial, social, financial, business, or close personal relationships with clients.) When a dual relationship cannot be avoided, counselors take appropriate professional precautions such as informed consent, consultation, supervision, and documentation to ensure that judgment is not impaired and no exploitation occurs. Termination: It is every client’s right to disengage from counseling with or without notice to the treatment provider. However, I request notification of termination of therapy. I find it helpful to arrange a final session to explore termination, and review counseling goals and progress. Please understand that your file will be considered closed 90 days after the last counseling appointment. Cancellation of Appointments: If you need to cancel your appointment, please let me know at least 24 hours in advance. Missed sessions or cancellations within 24 hours of a scheduled appointment will be charged at the hourly fee. Charges for missed sessions cannot be billed to insurance. Payment of Fees: Sessions begin at the scheduled time. The standard individual (50 minute) session fee is $160, standard individual (30 minute) session $80 and couples or family sessions are $160 (50 minute). Group (90-120 minute) session fee is $50. Initial Intake is $200. You can bring payments to session or be billed through PDS Billing at the beginning of each month for any co-pays or deductibles owing. Outstanding balances of more than 90 days will be sent to collections by another agency. Insurance Coverage & Payments: Insurance company carriers, plans, coverage and provider contracts are so varied in regards to mental health benefits that there is no way of guaranteeing that your insurance plan will cover my services for your diagnosis and counseling. Although I have a service that automatically bills insurance for all my clients unless requested to do otherwise, I STRONGLY advise each client to call their insurance company to estimate what coverage may apply before entering into therapy. Insurance companies require a formal diagnosis to determine eligibility for payment. Also, be aware that insurance company contracts with both clients and providers include authorizations to review actual counseling case notes if they request to do so. Insurance benefits are sent directly to my office and also sent to the client.

I ___________________ authorize Savannah Miller to engage in counseling services with me. I have read and understood the preceding disclosure and policy statements. I have also read and understood the Unprofessional Conduct handout. I understand I may have copies of both this contract and the Unprofessional Conduct form. I agree to the conditions of this therapy contract. _______________________________________ ______________________________________ Client’s Signature Date Parent/Guardian’s Signature (if applicable) Date

_______________________________________ ______________________________________ Client’s Signature Date Therapist/Counselor’s Signature Date

MEDICAL INFORMATION AND HISTORY

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Current Providers Primary medical practitioner: _________________________ Phone: ____________________________ Patient does _____ / does not _____ give permission to contact provider. Other medical specialists: 1) __________________________ Phone: ______________________ 2) ________________________________ Phone: ______________________ History of any of the following medical problems?

☐

cardio-vascular disease

☐ high blood pressure

☐ heart attack

☐ other heart problems

☐pulmonary problems

☐ urinary problems

☐ gastro-intestinal problems

☐ derma-tologic problems

☐ meno-pause

☐ immuno-deficiency

☐ other ________________

☐ neurological problems ❑ past history of closed head injury ❑ past history of stroke

Past hospitalizations/surgeries (when, where, reason): Past medications (name and conditions/symptoms treated): Are you being treated for any of the medical issues above? ☐ Yes ☐ No Are you willing to go for a medical evaluation? ☐ Yes ☐ No Are you being treated by a physician for any other current or chronic medical problems? If so, please explain: Allergies: Current Medications Rx: Reason: Dr: Rx: Reason: Dr: Rx: Reason: Dr: Rx: Reason: Dr: Rx: Reason: Dr:

Physical Fitness or Exercise Program? ☐ Yes ☐ No

Type:

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MENTAL HEALTH HISTORY Have you sought mental health or drug and alcohol counseling in the past? ☐ Yes ☐ No If yes, please explain (include previous practitioners/agencies, dates of treatment, type of treatment [i.e. individual, group, outpatient, inpatient, intensive outpatient] issues worked on, success of therapy): Are you currently receiving treatment from another mental health counseling provider? ☐ Yes ☐ No Mental health specialist / Agency: ____________________________ Phone: _______________________ Patient does _____ / does not _____ give permission to contact provider. Past mental health diagnoses: _________________________________________________________________ Have you had any inpatient psychiatric hospitalizations in the past? ☐ Yes ☐ No If yes, please explain (include dates of treatment, reasons for admittance, medications prescribed, success of treatment): Current mental health / psychiatric medications (i.e. for depression, anxiety, ADHD, bipolar, schizophrenia): Rx: Reason: Dr: Rx: Reason: Dr: Rx: Reason: Dr:

Assessment of Suicidal / Homicidal Behavior

1. In the past have you ever had any thoughts about hurting yourself or other people? ☐ Yes ☐ No

If yes, describe briefly. If no, skip to question 6. 2. Have you ever seriously contemplated hurting yourself or other people? ☐ Yes ☐ No

If yes, describe briefly. If no, skip to question 6. 3. Have you ever attempted to hurt yourself or hurt other people? ☐ Yes ☐ No If yes, describe all events where there has been a gesture or an attempt made to hurt self or others, including the dates,

circumstances, whether or not there was an intervention, and what type of intervention. If no, skip to question 6.

4. Within the past month have you had any thoughts about hurting yourself or hurting others? ☐ Yes ☐ No

If yes, please describe in terms of frequency, intensity, duration of thoughts and ideations. If no, please skip to question 6.

5. Have you ever thought about how you would hurt yourself or others? ☐ Yes ☐ No

If yes, describe (do you have access to weapons?): 9

SUBSTANCE USE

Questionnaire

1. Do you feel that you have any type of substance abuse problem? ☐ Yes ☐ No

2. Have you ever felt badly about drinking? ☐ Yes ☐ No

3. Have people ever criticized your drinking? ☐ Yes ☐ No

4. Have you ever not remembered what happened after drinking? ☐ Yes ☐ No

5. Have you ever had an early morning drink to calm your nerves? ☐ Yes ☐ No

6. Have you ever had a DUI or DWI? ☐ Yes ☐ No

7. Have you ever been treated for any type of substance abuse? ☐ Yes ☐ No Please describe:

Alcohol Have you used in the last 7 days? Y ☐ N ☐ Date of last use: _________ Amount consumed: _________ Amount consumed per week for last 6 months: _________ # times per week for last 6 months: ___________ Age at first use: ________ How do you usually consume (drink, swallow, inhale, inject, etc.)? ______________ Have you been prescribed medication? Y ☐ N ☐ If yes, what? ________________________________ Uppers (cocaine, crystal meth, etc.) Type used: _____________________________ Have you used in the last 7 days? Y ☐ N ☐ Date of last use: _________ Amount consumed: _________ Amount consumed per week for last 6 months: _________ # times per week for last 6 months: ___________ Age at first use: ________ How do you usually consume (drink, swallow, inhale, inject, etc.)? ______________ Have you been prescribed medication? Y ☐ N ☐ If yes, what? ________________________________ Marijuana Have you used in the last 7 days? Y ☐ N ☐ Date of last use: _________ Amount consumed: _________ Amount consumed per week for last 6 months: _________ # times per week for last 6 months: ___________ Age at first use: ________ How do you usually consume (drink, swallow, inhale, inject, etc.)? ______________ Have you been prescribed medication? Y ☐ N ☐ If yes, what? ________________________________

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Benzos (i.e. valium, Xanax) Type used: __________________ Have you used in the last 7 days? Y ☐ N ☐ Date of last use: _________ Amount consumed: _________ Amount consumed per week for last 6 months: _________ # times per week for last 6 months: ___________ Age at first use: ________ How do you usually consume (drink, swallow, inhale, inject, etc.)? ______________ Have you been prescribed medication? Y ☐ N ☐ If yes, what? ________________________________ Opiates (heroin, morphine, prescription pain killers, etc.) Type used: ____________________ Have you used in the last 7 days? Y ☐ N ☐ Date of last use: _________ Amount consumed: _________ Amount consumed per week for last 6 months: _________ # times per week for last 6 months: ___________ Age at first use: ________ How do you usually consume (drink, swallow, inhale, inject, etc.)? ______________ Have you been prescribed medication? Y ☐ N ☐ If yes, what? ________________________________ Nicotine (cigarettes, chewing tobacco, etc.) Type used: _________________________ Have you used in the last 7 days? Y ☐ N ☐ Date of last use: _________ Amount consumed: _________ Amount consumed per week for last 6 months: _________ # times per week for last 6 months: ___________ Age at first use: ________ How do you usually consume (drink, swallow, inhale, inject, etc.)? ______________ Have you been prescribed medication? Y ☐ N ☐ If yes, what? ________________________________ Caffeine (coffee, energy drinks, etc.) Type used: __________________________________ Have you used in the last 7 days? Y ☐ N ☐ Date of last use: _________ Amount consumed: _________ Amount consumed per week for last 6 months: _________ # times per week for last 6 months: ___________ Age at first use: ________ How do you usually consume (drink, swallow, inhale, inject, etc.)? ______________ Have you been prescribed medication? Y ☐ N ☐ If yes, what? ________________________________ Other type used: ______________________________________________ Have you used in the last 7 days? Y ☐ N ☐ Date of last use: _________ Amount consumed: _________ Amount consumed per week for last 6 months: _________ # times per week for last 6 months: ___________ Age at first use: ________ How do you usually consume (drink, swallow, inhale, inject, etc.)? ______________ Have you been prescribed medication? Y ☐ N ☐ If yes, what? ________________________________

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BECK DEPRESSION INVENTORY - Choose one statement from among the group of four statements in each question that best describes how you have been feeling during the past few days. Circle the number beside your choice. 1. Sadness 0. I do not feel sad. 1. I feel sad. 2. I am sad all the time and I can't snap out of it. 3. I am so sad or unhappy that I can't stand it.

2. Pessimism 0. I am not particularly discouraged about the future. 1. I feel discouraged about the future. 2. I feel I have nothing to look forward to. 3. I feel that the future is hopeless and that things cannot improve.

3. Past Failure 0. I do not feel like a failure. 1. I feel I have failed more than the average person. 2. As I look back on my life, all I can see is a lot of failure. 3. I feel I am a complete failure as a person.

4. Loss of Pleasure 0. I get as much satisfaction out of things as I used to. 1. I don't enjoy things the way I used to. 2. I don't get any real satisfaction out of anything anymore. 3. I am dissatisfied or bored with everything.

5. Guilty Feelings 0. I don't feel particularly guilty. 1. I feel guilty a good part of the time. 2. I feel quite guilty most of the time. 3. I feel guilty all of the time.

6. Punishment Feelings 0. I don't feel I am being punished. 1. I feel I may be punished. 2. I expect to be punished. 3. I feel I am being punished.

7. Self-Dislike 0. I don't feel disappointed in myself. 1. I am disappointed in myself. 2. I am disgusted with myself. 3. I hate myself.

8. Self-Criticalness 0. I don't feel I am any worse than anybody else. 1. I am critical of myself for my weaknesses or mistakes. 2. I blame myself all the time for my faults. 3. I blame myself for everything bad that happens.

9. Suicidal Thoughts or Wishes 0. I don't have any thoughts of killing myself. 1. I have thoughts of killing myself, but I would not carry them out. 2. I would like to kill myself. 3. I would kill myself if I had the chance.

10. Crying 0. I don't cry any more than usual. 1. I cry more now than I used to. 2. I cry all the time now. 3. I used to be able to cry, but now I can't cry even though I want to.

11. Agitation 0. I am no more restless or wound up than usual. 1. I feel more restless or wound up than usual. 2. I am so restless or agitated that it's hard to stay still. 3. I am so restless or agitated that I have to keep moving or doing something.

12. Interest 0. I have not lost interest in other people. 1. I am less interested in other people than I used to be. 2. I have lost most of my interest in other people. 3. I have lost all of my interest in other people.

13. Indecisiveness 0. I make decisions about as well as I ever could. 1. I put off making decisions more than I used to. 2. I have greater difficulty in making decisions than before. 3. I can't make decisions at all anymore.

14. Self Worth 0. I do not feel I am worthless 1. I don't consider myself as worthwhile and useful as I used to. 2. I feel more worthless as compared to other people. 3. I feel utterly worthless.

15. Energy 0. I have as much energy as ever. 1. I have less energy than I used to have. 2. I don't have enough energy to do very much. 3. I don't have enough energy to do anything.

16. Sleep 0. I can sleep as well as usual. 1. I don't sleep as well as I used to. 2. I wake up 1-2 hours earlier than usual and find it hard to get back to sleep. 3. I wake up several hours earlier than I used to and cannot get back to sleep.

17. Irritability 0. I am no more irritable than usual. 1. I am more irritable than usual. 2. I am much more irritable than usual. 3. I am irritable all the time.

18. Appetite 0. My appetite is no worse than usual. 1. My appetite is not as good as it used to be. 2. My appetite is much worse now. 3. I have no appetite at all anymore.

19. Concentration 0. I can concentrate as well as ever. 1. I can't concentrate as well as usual. 2. It's hard to keep my mind of anything for very long.

20. Fatigue 0. I don't get tired more than usual. 1. I get tired more easily than I used to. 2. I get tired from doing almost anything.

21. Interest in Sex 0. I have not noticed any recent change in my interest in sex. 1. I am less interested in sex than before 2. I am much less interested in sex now.

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3. I find I can't concentrate on anything. 3. I am too tired to do anything. 3. I have lost interest in sex completely.

BECK ANXIETY INVENTORY Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by circling the number in the corresponding space in the column next to each symptom.

Not At All

Mildly – it

didn’t bother me much

Moderately – it

wasn’t pleasant at times

Severely – it bothered me a lot

Numbness or tingling 0 1 2 3

Feeling hot 0 1 2 3

Wobbliness in legs 0 1 2 3

Unable to relax 0 1 2 3

Fear of worst happening 0 1 2 3

Dizzy or lightheaded 0 1 2 3

Heart pounding / racing 0 1 2 3

Unsteady 0 1 2 3

Terrified or afraid 0 1 2 3

Nervous 0 1 2 3

Feeling of choking 0 1 2 3

Hands trembling 0 1 2 3

Shaky / unsteady 0 1 2 3

Fear of losing control 0 1 2 3

Difficulty in breathing 0 1 2 3

Fear of dying 0 1 2 3

Scared 0 1 2 3

Indigestion 0 1 2 3

Faint / lightheaded 0 1 2 3

Face flushed 0 1 2 3

Hot / cold sweats 0 1 2 3

Column Sum

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SCORING (Beck Depression Inventory) 1 – 10: These ups and downs are considered normal. 11 – 16: Mild mood disturbance 17 – 20: Borderline clinical depression 21 – 30: Moderate depression 31 – 40: Severe depression

Over 40: Extreme depression ----------------------------------------------------------------------------------------------------------------- SCORING (Beck Anxiety Inventory) Sum each column. Then sum the column totals to achieve a grand score. Write that score here ____________. Interpretation

● A grand sum between 0 – 21 indicates very low anxiety. Commentary: That is usually a good thing. However, it is possible that you might be unrealistic in either your

assessment which would be denial or that you have learned to “mask” the symptoms commonly associated with anxiety. Too little “anxiety” could indicate that you are detached from yourself, others, or your environment.

● A grand sum between 22 – 35 indicates moderate anxiety. Commentary: Your body is trying to tell you something. Look for patterns as to when and why you experience

the symptoms described above. For example, if it occurs prior to public speaking and your job requires a lot of presentations you may want to find ways to calm yourself before speaking or let others do some of the presentations. You may have some conflict issues that need to be resolved. Clearly, it is not “panic” time but you want to find ways to manage the stress you feel.

● A grand sum that exceeds 36 is a potential cause for concern. Commentary: Again, look for patterns or times when you tend to feel the symptoms you have circled.

Persistent and high anxiety is not a sign of personal weakness or failure. It is, however, something that needs to be proactively treated or there could be significant impacts to you mentally and physically. You may want to consult a physician or counselor if the feelings persist.

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