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ALERT Adult Questionnaire
Jane Rekas, LCSW / LifeStance Health
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first name:
Your answer
Over the past week, how often have you felt/had:
nervousness/shakiness
not at all
a little
somewhat
a lot
Clear selection
sad or blue
not at all
a little
somewhat
a lot
Clear selection
hopeless
not at all
a little
somewhat
a lot
Clear selection
everything is an effort
not at all
a little
somewhat
a lot
Clear selection
no interest in things
not at all
a little
somewhat
a lot
Clear selection
your heart pounding or racing
not at all
a little
somewhat
a lot
Clear selection
trouble sleeping
not at all
a little
somewhat
a lot
Clear selection
fearful or afraid
not at all
a little
somewhat
a lot
Clear selection
difficulty at home
not at all
a little
somewhat
a lot
Clear selection
difficulty socially
not at all
a little
somewhat
a lot
Clear selection
thoughts of self harm
not at all
a little
somewhat
a lot
Clear selection
Your first name
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Your email
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