Brief Mood Survey (Before Session)
Please complete this form immediately *before* your session with Dr. Huberman, indicating how you feel *right now.*
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Your Name: *
Today's Date: *
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Where are you located right now, and whom could I contact in case of emergency (please provide name and number)?  If this information hasn't changed since you last gave it to me, feel free to write: "no change." *
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
Suicidal urges: Since we last met, have you
1. Felt that you'd be better off dead? *
Not at all
Extremely
2. Had suicidal thoughts or fantasies? *
Not at all
Extremely
3. Had urges or plans 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 happy and joyful. *
Not at all
Extremely
2. I feel hopeful and optimistic. *
Not at all
Extremely
3. I feel good about myself. *
Not at all
Extremely
4. I feel motivated and productive. *
Not at all
Extremely
5. I'm finding pleasure and satisfaction in life. *
Not at all
Extremely
How close do you feel to others right now?
1. I feel close and connected to others. *
Not at all
Extremely
Homework
How much psychotherapy homework have you done since your last session? *
Is there anything that you want to be sure we address in our session today?  If so, what?
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