Instructions: Welcome to the Therapy Needs Assessment Severity Index. This scale was created as a helpful tool to determine how urgent your potential need for therapy is. Please respond to the frequency of how often in the past month you have experienced the following symptoms of psychological dis-ease. If in doubt, opt the more frequent response as it is better to err on the side of caution when it comes to addressing our health needs.
Items: 30 Total
Time to Complete: 10 minutes
1.
How often in the past month have you experienced: Overuse of self-soothing (eating, porn, sleeping, sex, alcohol, substances)
2.
How often in the past month have you experienced: Emotional reaction bigger than the situation, having a short fuse
3.
How often in the past month have you experienced: Overwhelming bad mood (anxiety, depression, worry, anger)
4.
How often in the past month have you experienced: Acting impulsively and regretting it
5.
How often in the past month have you experienced: Feeling a sense of being lost, settling, or searching
6.
How often in the past month have you experienced: Fighting, drama or “toxic relationships”
7.
How often in the past month have you experienced: Having difficulty responding to texts or emails
8.
How often in the past month have you experienced: Apologizing when you did nothing wrong
9.
How often in the past month have you experienced: Mess, piles of to-dos, or clutter at home or work
10.
How often in the past month have you experienced: Difficulty meeting daily life needs (eg. showering, gym time, cooking)
11.
How often in the past month have you experienced: Not finding your interests interesting
12.
How often in the past month have you experienced: Infidelity or emotionally checking out of your relationship
13.
How often in the past month have you experienced: Cancelling plans or not being around other for 24 hours or more
14.
How often in the past month have you experienced: Chronic tardiness or absence at school or work
15.
How often in the past month have you experienced: Replaying conversations in your mind and criticizing yourself
16.
How often in the past month have you experienced: Losing hours on your phone
17.
How often in the past month have you experienced: Zoning out, misplacing items, losing track driving, or forgetting what you were preparing to do.
18.
How often in the past month have you experienced: Difficulty focusing, saying no, or making decision
19.
How often in the past month have you experienced: Physical dis-ease (e.g., pain, obesity, GI upset, muscle tension)
20.
How often in the past month have you experienced: Thoughts of what it would be like not to exist or suicidal thoughts
21.
How often in the past month have you experienced: Self-harm (physical or psychologically injuring yourself including punching a wall or hitting your head)
22.
How often in the past month have you experienced: Detaching, hiding out at home, isolating, or withdrawing from others.
23.
How often in the past month have you experienced: Failure to have and/or remember dreams
24.
How often in the past month have you experienced: Recurrent dream places, peoples, or themes
25.
How often in the past month have you experienced: Waking up before you wanted to or difficulty falling and staying asleep
26.
How often in the past month have you experienced: Sleeping too much or difficulty waking up on time
27.
How often in the past month have you experienced: Lack of restful sleep
28.
How often in the past month have you experienced: Nightmares or night terrors
29.
How often in the past month have you experienced: Disempowered vantage point in the dream (e.g., a car that won’t start, a gun that won’t fire, an inability to move the body as one might typically, being naked, violence)
30.
How often in the past month have you experienced: Waking with intensely unpleasant emotions
31.
How often in the past month have you experienced: Waking in a state of alert (e.g. sweating, painting, screaming, or crying)
32.
How often in the past month have you experienced: Dreams that you are ashamed or shocked that you dreamed
33.
How often in the past month have you experienced: Waking unable to shake anger or distrust of a loved one over events in your dreams.
Thank you for taking our survey. Please click the submit button to view your results below. Note: This is not a gimmick, you may use this or share this as many times as you like without any sign ups, phone calls, or request for an email. Simply push submit and your results will appear.
