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Symptom Rating Survey

Welcome to your Symptom Rating Survey

Name Email Phone Number
Please select the name of your counselor from the drop down list:
Are you currently receiving disability?
Are you currently seeking disability?
Are you currently involved in any lawsuits or legal disputes?

Willingness to Change


Instructions: Below you will find a list of things people do to try to overcome feelings of depression and anxiety. Indicate whether you'd be willing to try each activity if a therapist or trusted friend suggested it.

In order to recover, I'd be willing to:

1. Try new ways of relating to other people.
2. Get started on a task I've been avoiding or putting off.
3. Make a plan for solving the problems in my life.
4. Face a problem I've been avoiding.
5. Confront my fears, even if it makes me very anxious.

Relationship Survey


Instructions. Use checks to indicate whether you're having problems in any of the
following areas. Please answer all of the items.

Have you had any of problems –

6. At school? (Dx1)
7. In your work or career? (Dx2)
Have you had any problems or conflicts in your relationships with –

8. Your child or parents? (Dx3)
9. A brother or sister? (Dx4)
10. Your spouse or partner (Dx5)
11. Any abuse or violence in your relationship with a spouse or partner? (D6)
12. Any abuse, violence, or neglect in your childhood? (Dx7)
13. Are you struggling because of the death of a loved one? (Dx8)

Relationship Satisfaction Scale


Instructions. Use checks to indicate how satisfied or dissatisfied you feel about your relationship with some person.

Put his or her name here:
14. Communication and openness.
15. Resolving conflicts and arguments.
16. Degree of affection and caring.
17. Intimacy and closeness.
18. Overall satisfaction.

Anger Toward Yourself


Please select the following items to indicate how angry you've been feeling with yourself recently. Please answer all of the items.

19. Frustrated
20. Annoyed
21. Irritated.


Rachel Eddins, M.Ed., LPC-S, CGP on Twitter
Rachel Eddins, M.Ed., LPC-S, CGP
Rachel’s passion is to help people discover their personal gifts and strengths to achieve self-acceptance, create a healthy relationship with food, mind and body, and find meaning and fulfillment in work and life roles. She helps people create nurturance and healing from within to restore balance and enoughness and overcome binge eating, emotional eating, anxiety, depression and lack of career fulfillment.

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