PHQ9 GAD7 Assessment Form

You have been asked to complete this form as you either have an appointment scheduled with us or are coming towards the end of your sessions. It is useful for us to gather a picture of your current needs and how you are feeling.

The following questions are designed to help us understand your level of low mood and anxiety and your answers help to direct you to the right person or treatment. If you have an appointment, we will discuss these with you then. Please be as honest as you can, we appreciate some of the questions can be difficult.

*First Name *Last Name *Student Number

PHQ9 Form

Over the last two weeks how often have you been bothered by the following problems?

*1. Little interest or pleasure in doing things *2. Feeling down, depressed, or hopeless *3. Trouble falling or staying asleep, sleeping too much *4. Feeling tired or having little energy *5. Poor appetite or overeating *6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down *7. Trouble concentrating on things, such as reading the newspaper or watching television *8. Moving or speaking so slowly that other people could have noticed. Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual *9. Thoughts that you would be better off dead or of hurting yourself in some way

If you checked off any problems above:

*How difficult have these problems made it for you to do your work, take care of things at home or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult

GAD7 Form

Over the last 2 weeks, how often have you been bothered by the following problems?

*1. Feeling nervous, anxious or on edge *2. Not being able to stop or control worrying *3. Worrying too much about different things *4. Trouble relaxing *5. Being so restless that it's hard to sit still *6. Becoming easily annoyed or irritable *7. Feeling afraid as if something awful might happen

If you checked off any problems above:

*How difficult have these problems made it for you to do your work, take care of things at home or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult