Self-Referral Form

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Little interest or pleasure in doing things

Feeling down, depressed or hopeless

Trouble falling or staying asleep or sleeping too much

Feeling tired or having little energy

Poor appetite or over eating

Feeling bad about yourself or that you are a failure or have let yourself or your family down

Trouble concentrating on things such as reading the newspaper or watching television

Moving or speaking so slowly that other people could have noticed? or the opposite-being so fidgety or restless that you have been moving around a lot more than usual

Thoughts that you would be better off dead or hurting yourself in some way

Feeling nervous, anxious or on edge

Not being able to stop or control worrying

Worrying too much about different things

Trouble relaxing

Being so restless that it is hard to sit still

Becoming easily annoyed or irritable

Feeling afraid as if something awful might happen

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