DIRECTIONS: 

BEGIN: Print out this page with your printer.  Often using your CNTL (Control) and P keys at the same time will often start this process.

Read each numbered sentence. Then circle the number that feels most appropriate to you on the scale below the sentence. If you are unsure about what the sentence means, then read the paragraph below the scale. If the question seems pretty straightforward then answer that question and then skip to the next question. Continue this way through the remainder of the questions. When you are finished, go back and thoroughly read the paragraphs below the questions that interest you. Pay special attention to the questions that received the lowest scores.

1. How often do you feel lonely?

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frequently                                    rarely

Feeling lonely can be a sign of depression. If you are often feeling lonely, then consultation with a therapist can help.

2. Do you find yourself repeating unhealthful behavior patterns?

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often                 rarely                   never

When you feel compelled to do something that is harmful, such as smoking, drinking, overeating, excessive gambling, or abusing drugs or alcohol, then therapy is indicated.

3. Do you have someone or something to care for?

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no one, nothing                others need me

When you have a loved one, a pet, or even plants, then you are likely to feel valued and more emotionally healthy.

4. Have you had significant emotional losses with which you have not come to terms?  (Not only death, but also children leaving home.)

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many difficult losses                  few losses

If you have not allowed yourself to grieve and say good-by to lost loved ones, then you could benefit from talking to a therapist about healthy responses to loss.

5. Are you preoccupied with thoughts and fears about death?

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frequently                                       never

If thoughts of death are causing you distress, then talk to a therapist for assistance.

6. Are physical problems causing you emotional discomfort and/or frustration?

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much discomfort                             minor

Physical problems, especially when you have many of them, or when they are persistent, can be very difficult to handle. Even sexual changes or problems may be causing you distress.  Talk to a therapist if you need help.

7. Are you concerned about a physical problem you have?  Are you concerned about being a burden to others?

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not concerned              these are concerns

8. Do you have hobbies, interests, or work that you find interesting and enjoyable?

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none      few                           many interests

Having activities that you look forward to and that you find enjoyable, is a good sign of emotional health.

9. Do you have pain regularly?

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much pain                                  pain free

Pain can be your body's way of telling you that there is something wrong. Consult a doctor about your pain, and if it persists, have a therapist help you manage it.

10. How much transition or change is occurring in your life?

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major or                         minor or few changes

several changes 

Any transition, even ones that seem beneficial, can cause stress and upset your mental health. If you are experiencing several changes at once, or if you find that you are having trouble dealing with the changes in your life, then talk to a therapist.

11. Do you feel good about the major decisions that you have made in your life?

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don't feel good                       no regrets

Having regrets about the major decisions that you have made in your life can be a very difficult burden. Allow a therapist the chance to help you to see these decisions in a new light.

12. How is your sleep pattern?

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don't sleep well                     no problem

Your sleep pattern can easily be affected by your psychological state. It can also be altered by medications. If you feel that you are sleeping too much or not enough, then talk to a therapist. Nightmares and frequent awakenings can also be a sign of emotional problems.

13. Can you imagine good things happening to you in the future?

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no                                                     yes

If you can't imagine anything good happening to you in the future, then you may be depressed. Talk to a therapist about ways to brighten your outlook.

14. Do you have problems resulting from memory and/or concentration difficulties?

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often forgetful                           no difficulty

If you are having problems, then talk to a therapist who specializes in helping seniors.

15. Are you concerned about losing your job, and your related identity or maybe being replaced by a younger worker?  Are you concerned about facing retirement?

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not concerned                       these concern me

16. Do you feel that you have a sense of purpose and that you are needed?

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no                                                     yes

If your response to the last question was on the left side of the scale, then you may want to discuss these feelings with a therapist.

17. Do you have physical ailments for which the medical profession cannot find a cause?

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several                                            none

Therapists can be helpful with this type of problem.

18. Do you have family, friends, or neighbors with whom you are in contact and feel close?

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none          few                                several

If you don't have enough support, then a therapist can be of assistance.

19. Would you like to learn more about yourself and why you are the way you are?

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interested                              not interested

Therapy does not have to just focus on problems. It can be a medium for growth, self-awareness, and healing. If you would like to learn more, then talk to a therapist.

Results: Each of these questions probed a significant area of function in your life which can indicate that therapy is needed. If you would like to attain a higher score on this self-evaluation, then therapy can be of help. Therapy can give you a better understanding of your life and can also help you through the difficult times. If you scored close to 10 on all of the questions, then therapy is not likely to be of help at this time.

Call 1-800-THERAPIST or 1-800-843-7274 for more information.