SBQ
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
Jan
Feb
Mar
Apr
May
Jun
July
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
year
200
199
198
197
196
195
194
193
0
1
2
3
4
5
6
7
8
9
Name of therapist
Amanda Gutierrez
Kristen Dahlin
Liz Byrnes
Jay Weingarten
Rachel Slater
Dana
Brown
Group-only
Other
(primary therapist)
Filled out by
client
parent
other
Have you ever thought about or attempted to kill yourself in your lifetime?
No, never
It was just a passing thought.
I briefly considered it, but not seriously.
I thought about it and was somewhat serious.
I had a plan for killing myself which I thought would work and seriously considered it.
I attempted to kill myself, but I do not think I really meant to die.
I attempted to kill myself, and I think I really hoped to die.
How often have you thought about killing yourself...
Not at all
Rarely
Sometimes
Often
Very often
in your lifetime?
Not at all
Rarely
Sometimes
Often
Very often
in the last year?
Not at all
Rarely
Sometimes
Often
Very often
within the last 4 months?
Not at all
Rarely
Sometimes
Often
Very often
within the last month?
Not at all
Rarely
Sometimes
Often
Very often
in the last several days, including today?
Have you ever told someone that you were going to commit suicide, or that you might do it...
No
Yes, during one short period of time
Yes, during more than one period of time
in your lifetime?
No
Yes, during one short period of time
Yes, during more than one period of time
in the last year?
No
Yes, during one short period of time
Yes, during more than one period of time
within the last 4 months?
No
Yes, during one short period of time
Yes, during more than one period of time
within the last month?
No
Yes, during one short period of time
Yes, during more than one period of time
in the last several days, including today?
What chance is there that you will consider the possibility, no matter how remote, of killing yourself...
0 - No chance at all
1
2 - Some chance
3
4 - Very likely
in your lifetime?
0 - No chance at all
1
2 - Some chance
3
4 - Very likely
within the next year?
0 - No chance at all
1
2 - Some chance
3
4 - Very likely
within the next 4 months?
0 - No chance at all
1
2 - Some chance
3
4 - Very likely
within the next month?
0 - No chance at all
1
2 - Some chance
3
4 - Very likely
today or in the next several days?
How likely is it that you will attempt suicide...
0 - No chance at all
1
2 - Some chance
3
4 - Very likely
in your lifetime?
0 - No chance at all
1
2 - Some chance
3
4 - Very likely
within the next year?
0 - No chance at all
1
2 - Some chance
3
4 - Very likely
within the next 4 months?
0 - No chance at all
1
2 - Some chance
3
4 - Very likely
within the next month?
0 - No chance at all
1
2 - Some chance
3
4 - Very likely
today or in the next several days?
If you did attempt suicide, for any reason, how likely is it that you would die as a result...
0 - No chance at all
1
2 - Some chance
3
4 - Very likely
in your lifetime?
0 - No chance at all
1
2 - Some chance
3
4 - Very likely
within the next year?
0 - No chance at all
1
2 - Some chance
3
4 - Very likely
within the next 4 months?
0 - No chance at all
1
2 - Some chance
3
4 - Very likely
within the next month?
0 - No chance at all
1
2 - Some chance
3
4 - Very likely
today or in the next several days?
Do you currently have a plan for how you would go about killing yourself, if you decided to do it?
No
Yes, a vague plan
Yes, a definite plan
Have you recently been planning for not being alive (for example, giving away your possessions or planning for someone to care for pets or manage your other responsibilities)?
No
Yes, somewhat
Yes, quite a bit
Sometimes people who decide to kill themselves want to do it but can not find a way to actually carry through with their plan because the means are not available to them. If you decided to kill yourself at this point in your life, would the means for carrying out such an action be available to you?
No
Yes, possibly
Yes, definitely
If you decided to kill yourself at this point in your life, is there someone in your environment who would want to stop you?
No
Yes, to a small degree
Yes, very much so
Some individuals say they cannot even imagine or conceive of the idea of attempting or committing suicide. For these people, suicidal behavior is as alien as the thought of becoming a tree or lifting the Empire State Building. Other people, even though they might never actually consider the idea, can at least imagine the idea of attempting or considering suicide. Which group of people do you belong to?
Group who definitely can not imagine
Group who can somewhat imagine
Group who can definitely imagine
Would any of your problems be solved if you committed suicide?
No, definitely not
Maybe
Yes, definitely
Thinking about the way your life is today, that is, given the good things in your life now and any problems you might be having, IF you knew the QUALITY of your life would never change, that is, it would never get better or worse, do you feel that suicide would be a good way out?
No, definitely not
Maybe
Yes, definitely
If the QUALITY of your life were to get worse (very bad), do you feel that attempting suicide would solve any of your problems?
No, definitely not
Maybe
Yes, definitely
Have you ever written a suicide note, even if another person never read it?
No, definitely not
Maybe
Yes, definitely
Have any of your family members or friends ever committed suicide?
No, definitely not
Maybe
Yes, definitely
Have you ever deliberately hurt yourself physically (such as cut or burned yourself), but were not trying or expecting to die?
No
Yes, and the most recent time was:
in the last 7 days
in the last 14 days
in the last 30 days
in the last 2 months
in the last year
more than 1 year ago
The questions below apply to the last week. Select the most appropriate statements.
How often have you thought about injuring yourself or about how you want to injure yourself?
Never, 0 times in the last week
Rarely, 1-2 times in the last week
Occasionally, 3-4 times in the last week
Sometimes, 5-10 times in the last week, or 1-2 times a day
Often, 11-20 times in the last week, or 2-3 times a day
Most of the time, 20-40 times in the last week, or 3-6 times a day
Nearly all of the time, more that 40 times in the last week, or more than 6 times a day
At the most severe point, how strong was your urge to self-injure in the last week?
None at all
Slight, that is, a very mild urge
Mild Urge
Moderate Urge
Strong Urge, but easily controlled
Strong Urge, but difficult to control
Strong Urge and would have self-injured if able to
How much time have you spent thinking about injuring yourself or about how you want to injure yourself?
None
Less than 20 min.
21-45 min.
46-90 min.
90 min to 3 hrs.
3-6 hrs.
More than 6 hrs.
How difficult was it to resist injuring yourself in the last week?
Not difficult at all
Very mildly difficult
Mildly difficult
Moderately difficult
Very difficult
Extremely difficult
Was not able to resist
Keeping in mind your responses to the previous questions, please rate your overall average urge or desire to injure yourself in the last week.
Never thought about it and never had the urge to self-injure
Rarely thought about it and rarely had the urge to self-injure
Occasionally thought about it and occasionally had the urge to self-injure
Sometimes thought about it and sometimes had the urge to self-injure
Often thought about it and often had the urge to self-injure
Thought about self-injury most of the time and had the urge to do it most of the time
Thought about self-injury nearly all the time and had the urge to do it nearly all the time
pre-treatment
CP
PB
AG
JW
KD
LB
MZB
ALB