Your birthdate and date of your first DBTCSD therapy session are needed for us to identify your data while keeping it anonymous to others. Your data will be transmitted securely as scrambled numbers without any text labels.
Birthday year
Name of therapist (primary therapist)
Filled out by

In the following questions you will find a set of difficulties and problems which possibly describe you. Decide how much you suffered from each problem during the course of the last week:
    0 = not at all
    1 = a little
    2 = moderately
    3 = quite a bit
    4 = extremely
In you are uncertain, please answer according to how you think you might have felt. Please answer honestly. All questions refer to the last week. If you felt different ways at different times in the week, give a rating for how things were for you on average. Please be sure to answer each question.

Not A Moder Quite
at all Little -ately a bit Extremely During the course of last week...
It was hard for me to concentrate
I felt helpless
I was absent-minded and unable to remember what I was actually doing
I felt disgust
I thought of hurting myself
I didn't trust other people
I didn't believe in my right to live
I was lonely
I experienced stressful inner tension
I had images that I was very much afraid of
I hated myself
I wanted to punish myself
I suffered from shame
My mood rapidly shifted between anxiety, anger, and depression
I suffered from voices and noises from inside and/or outside my head
Criticism had a devastating effect on me
I felt vulnerable
The idea of death had a certain fascination for me
Everything seemed senseless to me
I was afraid of losing control
I felt disgusted with myself
I felt as if I was far away from myself
I felt worthless

Filled out on