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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:

1 out of 26

Are you currently receiving disability?

2 out of 26

Are you currently seeking disability?

3 out of 26

Are you currently involved in any lawsuits or legal disputes?

4 out of 26

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.

5 out of 26

2. Get started on a task I've been avoiding or putting off.

6 out of 26

3. Make a plan for solving the problems in my life.

7 out of 26

4. Face a problem I've been avoiding.

8 out of 26

5. Confront my fears, even if it makes me very anxious.

9 out of 26

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)

10 out of 26

7. In your work or career? (Dx2)

11 out of 26

Have you had any problems or conflicts in your relationships with –

8. Your child or parents? (Dx3)

12 out of 26

9. A brother or sister? (Dx4)

13 out of 26

10. Your spouse or partner (Dx5)

14 out of 26

11. Any abuse or violence in your relationship with a spouse or partner? (D6)

15 out of 26

12. Any abuse, violence, or neglect in your childhood? (Dx7)

16 out of 26

13. Are you struggling because of the death of a loved one? (Dx8)

17 out of 26

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:

18 out of 26

14. Communication and openness.

19 out of 26

15. Resolving conflicts and arguments.

20 out of 26

16. Degree of affection and caring.

21 out of 26

17. Intimacy and closeness.

22 out of 26

18. Overall satisfaction.

23 out of 26

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

24 out of 26

20. Annoyed

25 out of 26

21. Irritated.

26 out of 26


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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