Jeremy Cassius, M.Ed, LPC Licensure #65426 NPI:1437359130 4100 Spring Valley Rd, Suite #275, Dallas, Texas 75244 Phone: 214-830-8214 Fax: 866-242-3378
Date:
CRTN:
CRF number:
Beck Depression Inventory
Name
Marital Status:
Age:
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Instructions: This questionnaire consists of 21 groups of statements. Please read each group of statements carefully and then pick out one statement in each group that best describes the way you have been feeling during the past two weeks,including today.
1. Sadness
I do not feel sadI feel sad much of the timeI am sad all the timeI am so sad or unhappy that I cant stand it
2. Pessimism
I am not discouraged about my futureI feel more discouraged about my future than I used to beI do not expect things to work out for meI feel my future is hopeless and will only get worse
Mood/Depression Assessment Questionnaire
1.Since your last visit have you felt depressed, sad or blue much of the time?
YesNo
2.Since your last visit have you often felt helpless about the future?
3.Since your last visit have you has little interest or pleasure in doing things?
4.Since your last visit have you had trouble sleeping many nights?
Patient's Signature
Clinician’s Signature
This checkbox verifies all information on this form is true.