Beck Depression Inventory

    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:

    Sex:

    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

    2. Pessimism

    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?

    YesNo

    3.Since your last visit have you has little interest or pleasure in doing things?

    YesNo

    4.Since your last visit have you had trouble sleeping many nights?

    YesNo

     

    Patient's Signature

    Clinician’s Signature

    This checkbox verifies all information on this form is true.