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)
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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.

In social situations where it is possible that you will be noticed or evaluated by other people, do you feel excessively nervous, fearful or uncomfortable?
Do you tend to be overly worried that you may act in a way that might embarrass or humiliate yourself in front of other people, or that others may not think well of you?
Do you try to avoid social situations?

Below is a list of some situations that are fear provoking for some people. Rate the severity of your anxiety and avoidance on the following scales:
0 = No fear0 = Never avoid
1 = mild fear1 = Rarely avoid
2 = Moderate fear2 = Sometimes avoid
3 = Severe fear3 = Often avoid
4 = Very severe fear4 = Always avoid
.0 . 1 . 2 . 3 . 4.0 . 1 . 2 . 3 . 4
Eating in a public location
Using public bathrooms when others are present
Becoming the focus of attention
Writing in front of other people
    (signing checks, filling out forms)
Dating circumstances
A first date
Meeting people in authority
Speaking with people in authority
Saying 'no' to unreasonable request
Asking others to do something differently
Being introduced
Initiating a conversation
Keeping a conversation going
Giving a speech
Using the telephone
Others judging you
Being under observation by others
Being teased

Do you tend to experience fear each time you are in feared social situations?
Does the fear come on as soon as you encounter feared social situations?
Would you say that your social fear is excessive or unreasonable?
Has what you have been able to achieve in your job or in school been negatively effected by your social fear?

Select the degree to which your social fear interferes with your life, work, social activities, family, etc?
How distressing do you find your social fear??