Depression Assessment

Use this form to evaluate your level of depression. You may use the "tab" key to move to the next selection; you may then enter your number (rather than using the pull-down selection) to make your selection more quickly. To select "10" with this shortcut, enter the number 9 and use your arrow key to go down to 10.
Client Name: Date:

How true was this for you lately?  Rate 0 - 10 Frequency Intensity Duration Total
Worry (without reasonable cause)
Futility; feelings of uselessness
Sad mood (for no reason, over little things)
Feelings of hopelessness or pessimism
Feelings of helplessness or despair
Guilty feelings (for no reason)
Dwelling on the past
Irritability (angry even over little things)
Conviction that your endeavors are meaningless
Unable to concentrate, make decisions, study
Feeling angry, sullen, bitter, resentful
Decreased thought processes
Sense of dread and fear of dying
How true was this for you lately?  Rate 0 - 10 Frequency Intensity Duration Total
Change in weight during past two months
Fatigue, low level of energy
Sleep disturbance, insomnia, early awakenings
Confusion, memory lapses
Decrease in sex drive
Crying spells, or feeling like crying
Apathy, loss of motivation
Loss of interest in favorite things and activities
Poor grooming, sloppy appearance, unkempt
Withdrawal, feeling isolated
Loss of sense of humor, difficulty in laughing
Introspection and introversion, self-centered
Inferiority feelings
Feeling unloved, unwanted, unappreciated
Feeling worthless
How true was this for you lately?  Rate 0 - 10 Frequency Intensity Duration Total
Depersonalization (leaving your body)
Lack of warm feelings, emotions, or interests
Fear of rejection & desire to be close
Clinging behavior
Defensiveness, denial, displacement
Paranoid, afraid people are mad at you
Masochism (seeking painful experiences)
Back pain
Indigestion, constipation, or heartburn
Other aches and pains
Suicidal thoughts or escape fantasies
Cutting on or hurting yourself
A plan to commit suicide
An attempt to commit suicide
Total factors selected: out of 45 Total score:  




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Appointments scheduled for you are set aside expressly for you, therefore any not kept will be billed unless canceled 48 hours in advance.

Dr. Ray Smith


Ray Wm. Smith, Ed.D
9507 N Division Street Suite A
Spokane, WA 99218-1556

Phone: (509) 466-6632
Fax: (509) 466-0117
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Office Hours:
Monday - Friday, 8 a.m. - 8 p.m.
Saturday Mornings