BSL

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BSL

Your birthdate and date of your first DBTCSD therapy session are needed for us to identify your data while keeping it anonymous to others. Your data will be transmitted securely as scrambled numbers without any text labels.

Birthday *

YYYY

Name

In the following questions you will find a set of difficulties and problems which possibly describe you. Decide how much you suffered from each problem during the course of the last week: 0 = not at all / 1 = a little / 2 = moderately / 3 = quite a bit / 4 = extremely

In you are uncertain, please answer according to how you think you might have felt. Please answer honestly. All questions refer to the last week. If you felt different ways at different times in the week, give a rating for how things were for you on average. Please be sure to answer each question.

During the course of last week...

0 - Not at all

1 - A little

2 - Moderately

3 - Quite a bit

4 - Extemely

It was hard for me to concentrate

I felt helpless

I was absent minded and unable to remember what I was doing

I felt disgust

I thought of hurting myself

I didn't trust other people

I didn't believe in my right to live

I was lonely

Clear selection

During the course of last week...

0 - Not at all

1 - A little

2 - Moderately

3 - Quite a bit

4 - Extemely

I experienced stressful inner tension

I has images that I was very much afraid of

I hated myself

I wanted to punish myself

I suffered from shame

My mood rapidly shifted between, anxiety, anger, and depression

I suffered from voices and noises from inside and/or outside my head

Criticism had a devastating effect on me

Clear selection

During the course of last week...

0 - Not at all

1 - A little

2 - Moderately

3 - Quite a bit

4 - Extemely

I felt vulnerable

The idea of death had a certain fascination for me

Everything seemed sensless to me

I was afraid of losing control

I felt disgusted with myself

I felt as if I was far away from myself

I felt worthless

Clear selection

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