DERS-18

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

DERS-18

Your birthdate helps us identify your data accurately.

Birthday *

YYYY

Your First Name *

Filled out by *

Client

Parent

CHECK THE ONE RESPONSE TO EACH ITEM THAT BEST DESCRIBES YOU FOR THE PAST SEVEN DAYS.

During the past 7 days...

I pay attention to how I feel. *

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

I have no idea how I am feeling. *

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

I have difficulty making sense out of my feelings. *

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

I am attentive to my feelings. *

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

I am confused about how I feel. *

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

When I’m upset, I acknowledge my emotions. *

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

When I’m upset, I become embarrassed for feeling that way. *

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

When I’m upset, I have difficulty getting work done.

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

Clear selection

When I’m upset, I become out of control.

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

Clear selection

In the past 7 days...

When I'm upset, I believe that I will remain that way for a long time. *

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

When I'm upset, I believe that I'll end up feeling very depressed. *

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

When I'm upset, I have difficulty focusing on other things. *

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

When I'm upset, I feel ashamed with myself for feeling that way. *

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

When I'm upset, I feel guilty for feeling that way. *

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

When I'm upset, I have difficulty concentrating. *

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

When I'm upset, I have difficulty controlling my behaviors. *

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

When I'm upset, I believe that wallowing in it is all I can do.

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

Clear selection

When I'm upset, I lose control over my behaviors.

1- Almost Never (0-10%)

2- Sometimes (11-35%)

3- About Half the Time (36-65%)

4- Most of the Time (66-90%)

5- Almost Always (91-100%)

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of DBT San Diego.

Does this form look suspicious? Report

Forms