Brief Mood Survey (Before Session)
Please complete this form immediately *before* your session with Dr. Huberman, indicating how you feel *right now.*
Your Name: *
Today's Date: *
MM
/
DD
/
YYYY
How depressed do you feel right now?
1. Sad or down in the dumps *
Not at all
Extremely
2. Discouraged or hopeless *
Not at all
Extremely
3. Low self-esteem, inferiority, or worthlessness *
Not at all
Extremely
4. Loss of motivation to do things *
Not at all
Extremely
5. Loss of pleasure or satisfaction in life *
Not at all
Extremely
How suicidal do you feel right now?
1. Do you have any suicidal thoughts? *
Not at all
Extremely
2. Would you like to end your life? *
Not at all
Extremely
How anxious do you feel right now?
1. Anxious *
Not at all
Extremely
2. Frightened *
Not at all
Extremely
3. Worrying about things *
Not at all
Extremely
4. Tense or on edge *
Not at all
Extremely
5. Nervous *
Not at all
Extremely
How angry do you feel right now?
1. Frustrated *
Not at all
Extremely
2. Annoyed *
Not at all
Extremely
3. Resentful *
Not at all
Extremely
4. Angry *
Not at all
Extremely
5. Irritated *
Not at all
Extremely
Positive Feelings
How do you feel right now?
1. I feel worthwile *
Not at all
Extremely
2. I feel good about myself *
Not at all
Extremely
3. I feel close to people *
Not at all
Extremely
4. I feel I am accomplishing something *
Not at all
Extremely
5. I feel motivated to do things *
Not at all
Extremely
6. I feel calm and relaxed. *
Not at all
Extremely
7. I feel a connection to others. *
Not at all
Extremely
8. I feel hopeful. *
Not at all
Extremely
9. I feel encouraged and optimistic. *
Not at all
Extremely
10. My life is satisfying *
Not at all
Extremely
Is there anything that you want to be sure we address in our session today? If so, what?
Submit
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