Is Therapy Right for Me?

Self-Assessment Questionnaire

Instructions: Read each statement and select the response that best describes your experience over the past 4 weeks. There are no right or wrong answers — answer as honestly as you can. This questionnaire is a screening tool, not a diagnostic instrument, and does not replace a conversation with a licensed mental health professional.
Scale: 0 = Not at all  •  1 = A little  •  2 = Moderately  •  3 = Quite a bit  •  4 = Extremely

Section A: Emotional Well-Being

1. I feel sad, down, or low more days than not.

2. I feel anxious, tense, or on edge much of the time.

3. My mood swings unpredictably or feels hard to control.

4. I feel numb or disconnected from my emotions.

5. I have lost interest or pleasure in things I used to enjoy.

6. I feel irritable or "on edge" in ways that surprise me or others.

Section B: Daily Functioning

7. It's hard to concentrate at work, school, or on daily tasks.

8. My sleep has been disrupted (too much, too little, or poor quality).

9. My appetite or eating habits have changed noticeably.

10. I'm having trouble keeping up with responsibilities (work, home, family).

11. I've been avoiding people, places, or activities I used to engage with.

12. My energy levels feel much lower than usual.

Section C: Relationships & Social Life

13. I've been withdrawing from friends or family.

14. I have conflicts in my relationships that feel hard to resolve on my own.

15. I feel lonely or misunderstood, even around people I care about.

16. I find it difficult to trust or open up to others.

Section D: Coping & Stress

17. I feel overwhelmed by stress more often than I'd like.

18. I use unhealthy habits (e.g., overworking, substances, avoidance) to cope.

19. I feel like I don't have effective tools to manage difficult emotions.

20. Small setbacks feel much bigger or harder to bounce back from than they used to.

Section E: Self-Perception & Outlook

21. I'm frequently self-critical or feel like I'm not good enough.

22. I feel uncertain about my identity, values, or direction in life.

23. I've experienced a major life change, loss, or stressor recently that I'm still processing.

24. I've thought that talking to a professional might help me.

25. Overall, I feel my quality of life is lower than I would like it to be.

This questionnaire is intended as a conversation-starting and screening aid for use by, or under the guidance of, a qualified mental health professional. It is not a validated diagnostic instrument and does not screen for risk of self-harm, suicidal ideation, or other safety concerns.

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