Contact Information

1. How is your day to day mood?

2. Social interactions

3. Suicidal thoughts [and/or actions]

4. I self-harm [scratching, cutting, drugging, drinking etc.]

5. Sexual interest

6. Appetite

7. Weight

8. I remember past events and think “what if”

9. I remember things as always being bad

10. Guilt and/or low self-esteem and/or worthlessness etc.:

11. I feel very tired when I am should normally be awake and alert:

12. I find hard to concentrate: